Autism spectrum disorders are neurodevelopmental disorders that affect all areas of a child’s development. They are biologically based and there is good evidence that they have a genetic basis, though there seem to be many genes involved. The term autism spectrum disorder generally refers to three pervasive developmental disorders:
- Autistic disorder (or autism)
- Asperger’s disorder (or Asperger syndrome)
- Pervasive developmental disorder not otherwise specified (or PDDNOS for short).
Autism spectrum disorders affect three major areas of children’s development:
- social interaction
- communication
- behaviour.
Children with autism (autistic disorder) are affected significantly in all areas, and many may not speak. The majority of children with autism have an intellectual disability; children with autism who do not have an intellectual disability are referred to as having high-functioning autism.
Children with Asperger’s disorder (Asperger’s syndrome) are affected in their social interaction and behaviour, and the social use of language (e.g., conversations), but their language development generally develops normally. Generally these children do not have an intellectual disability.
Children with PDDNOS are also affected in these areas. They have significantly affected social interaction associated with less severe communication or behaviour difficulties, thus they do not meet the all the diagnostic criteria for either Autistic disorder or Asperger’s disorder. They may or may not have an intellectual disability.
Social interaction
From infancy typically developing children learn about their social world, develop social skills, and learn to make inferences about other people’s behaviour and feelings. They watch what others do and say, and imitate others. They pay attention to facial expressions, body language, and spoken language, and they use facial expression, body language and spoken language to communicate with others. Children with autism spectrum disorder don’t automatically pay attention to their social world or learn these social skills. Social difficulties may look different depending on the child’s:
- age
- language and communication
- developmental delay or intellectual disability.
Children with autism often have poor eye contact; they don’t point out or share interesting things they see with others; they don’t bring toys or interesting objects to share with mum or dad; and they often show little interest in other people. Young children with autism don’t usually take part in simple social games, or imitate mum or dad around the house. They mostly show interest in others when they need something themselves. They have difficulty understanding other people’s behaviour and are generally happy to be on their own.
Even when children with an autism spectrum disorder have good language skills they still don’t understand other people’s behaviour, and they don’t usually share new and interesting activities or accomplishments with other people. They may be interested in other children, but they have difficulty understanding how to join in. If they play with other children, they may want to direct the play ‘their way’, or they can’t follow rapidly changing rules or play sequences.
Often parents say that they think their child does not really understand emotions. This is because children with an autism spectrum disorder have difficulty understanding both other people’s emotions and their own emotions. They may appear to lack empathy, for example, not responding when someone is crying.
Difficulties with social interactions and social understanding mean that children with an autism spectrum disorder often have difficulty making friends and getting on with their peers; some children do not seem interested in making friends.
While some children with an autism spectrum disorder may be imaginative, they are not as imaginative as typically developing children; overall children with autism spectrum disorder have poor imagination. Play in children with autism spectrum disorder can be repetitive and lack imagination. For example, some young children with autism may be happy to sit for a long time putting blocks in a line, or running a car up and down across the floor while watching the wheels.
Talking and communication
Talking is not really the same as communicating. If you meet someone who does not speak your language, you try to communicate by gesturing, making faces, using signs and repeating simple words.
For children with an autism spectrum disorder, communication is a major area of difficulty. Even when they can speak very well, children with an autism spectrum disorder have subtle communication difficulties. They also have difficulty with non-verbal communication like gestures and ‘reading’ people’s facial expressions.
Children with autism often use echolalia, that is, they repeat what they hear or others say to them. They may have trouble using pronouns replying,’ You want teddy’ to mean that they want their teddy.
Children with Asperger’s disorder learn to talk at the expected age, but have more subtle difficulties like carrying out a conversation, understanding how to change conversation topics, or realising that someone is getting bored. They like to tell you about their favourite interest like football teams, or dinosaurs, but generally don’t talk to just have a chat. When they get older and learn to talk well, children with high-functioning autism have similar conversational difficulties.
Children who learn to speak well may take what people say literally, for example if you say, ‘You’d better pull your socks up’, meaning that you want your child to do better or try harder, the child with an autism spectrum disorder will most likely simply pull up their socks, or if they are not wearing socks, be confused. Children will also have trouble understanding jokes, and prefer obvious or slap stick humour.
Some children with autism may not talk but they learn to use various forms of picture cues to indicate what they want, for example, pointing to a picture of a drink, when they want one. They can also learn simple signs.
Children with an autism spectrum disorder also have trouble with using gestures and body language to communicate. Typical young children easily learn gestures like shaking their head for ‘yes’ or ‘no’, shoulder shrugs, smiling at others, waving goodbye and pointing to things of interest. However, you have to teach a young child with an autism spectrum disorder to use gestures like waving goodbye; even when he learns to wave the child has to be reminded, and often does not turn around to look as he waves.
Social skills and verbal and non-verbal communication skills are closely tied together – they are our means of interacting with others and making friends.
Behaviour
The third area of difficulty for children with an autism spectrum disorder is behaviour. Children with an autism spectrum disorder generally don’t show all of these behaviours. Most of these behaviours can also occur in other children, for example in very young children and in children with an intellectual disability.
Children with an autism spectrum disorder may have difficult and challenging behaviours including tantrums; they may not like change inside or outside home, often like to follow set routines or rituals, may have restricted interests like a collection, for example, bits of string or a card series, or asking questions that have to be answered a particular way.
When things happen in a regular way they are predictable. When changes occur your child may not understand what is happening around him; if you tidy his bedroom or take a different route to school, because your child does not understand he becomes distressed. If your child wants something and can’t communicate he may also become distressed.
Children with an autism spectrum disorder often have odd motor movements like jumping up and down and flapping with excitement or pleasure, walking on tip-toes, and rocking and/or pacing. Behaviours like rocking or pacing are something that we may all do if we are under stress or anxious, and it is likely that this is why children with autism also do this. These repetitive behaviours can also provide stimulation.
Children with an autism spectrum disorder may be sensitive to sights, sounds, smells, touch and other environmental stimuli. They seem more susceptible to sensory overload than other children and this may trigger difficult behaviour. This may be because they have trouble coping with lots of different information at once.
There is a range of other behaviours that children with autism spectrum disorder may have more often than other children. These include:
- food fads, which may be related to the sensory properties of food or because of a desire for predictability and sameness
- sleep problems, especially settling to sleep and night waking
- being very late with toilet training.
The difficulty that children with an autism spectrum disorder have understanding other people, and communicating with others, can sometimes make it tricky to work out why a particular difficult behaviour is occurring.
Prevalence
A recent Australian study1 found that one in 160 Australian primary school age children have an autism spectrum disorder. In late 2009 the Centers for Disease Control (CDC) in the U.S.A. suggested that about one per cent or one in 110 children have an autism spectrum disorder2. There has been a steady increase in prevalence, some of which can be accounted for by increased public awareness and changes in diagnostic practice.
Boys and girls
There are about four times more boys than girls with an autism spectrum disorder, and we think that there are even more boys than girls who have Asperger’s disorder. However, researchers are now interested in whether we might be missing some high-functioning girls because their behaviour patterns might differ in some ways from those of high-functioning boys.
Diagnosing autism spectrum disorders
There is no simple medical or psychological ‘test’ for an autism spectrum disorder; they are diagnosed using specific criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR). They are diagnosed by finding out about a child’s development from birth, by talking to parents, teachers and other relevant adults, and by observing the child’s behaviour and interacting with the child. There are also some questionnaires that can indicate whether or not an autism spectrum disorder might be present but these are not sufficient on their own. The Autism Diagnostic Observation Schedule (ADOS) is also very helpful in deciding whether or not a child has an autism spectrum disorder. The ADOS can only be used by ADOS-trained professionals.
As all areas of the child’s development need to be assessed, a diagnosis and assessment generally involves a paediatrician (or child psychiatrist), a psychologist and a speech pathologist. Sometimes an occupational therapist is also involved.
If parents are concerned that their child has the kinds of behaviours described above, then they should speak about their concerns with their health professional or maternal and child health nurse. It is now often possible to diagnose an autism spectrum disorder in children as young as 18 months to two years. Videos showing the early signs of autism across all areas of development can be found on the Autism Speaks’ website3.
Treating autism spectrum disorders
Just as there are no simple medical tests for diagnosing autism spectrum disorders, there are no medications that can cure them. Autism spectrum disorders are generally life-long disorders though change and improvements occur as the child gets older. In a small percentage of cases, children may markedly improve such that they no longer meet all the criteria for an autism spectrum disorder. At present we cannot predict which children will do this though they usually come from the group of children who have better language skills and normal intellectual skills by about six years. Early intervention also seems to be an important factor when there is such marked improvement.
Early intervention that is developmentally sequenced and behaviourally based has the most scientific support for treating children with an autism spectrum disorder. Early intervention that is based on the principles of applied behaviour analysis, developmentally sequenced, addresses all areas of development, and is individualised and intensive (averages at about 15–20 hours per week) have the most scientific support. This includes programs like that of Lovaas4 and colleagues, often referred to as ABA (Applied Behaviour Analysis) treatment or Discrete Trial Training (DTT); and the Denver Early Start Model5 . Applied behaviour analysis techniques are also helpful for addressing individual behaviours or areas of concern.
There are many promises of miracle cures for autism spectrum disorders that have no scientific support either for the theory that underpins the intervention or for the effectiveness of the intervention itself. Many cost a lot of money, and some may be harmful to the child.
Parents should always carefully evaluate the evidence for effectiveness of a proposed intervention, costs involved, and the qualifications and autism-relevant experience of those offering an intervention. Information about interventions and evaluating interventions can be found on the Raising Children Network6.
Is medication useful?
Medications can be useful for treating particular co-existing medical or behavioural conditions that children with an autism spectrum disorder may have. This includes medication for epilepsy which occurs in about 25 per cent of children with autism, or medication to assist with significant attentional problems, hyperactivity, self-injurious behaviour, significant aggression, anxiety, or mood problems.
What can parents do?
Parents know their child best. Parents can help by being involved with their child’s teachers and early intervention or school program. Your child’s teachers will be able to provide you with strategies to help you with your child at home. As with all children, spending time interacting with your child with an autism spectrum disorder is important. Parents of young children can learn more by attending the Early Days workshops7. Positive Partnerships8 provides programs for parents and teachers of school age children. The Raising Children Network also has a range of information sheets and video clips about autism spectrum disorders, including information about things parents can do, and more are to come.
Many parents find support and help by joining a parent support group. Your state autism association will have a list of parent support groups in your state. As well the Raising Children Network6 also has a parent forum for parents of children with an autism spectrum disorder, which you can join.
Two recent books that parents might find helpful are:
O’Reilly, B., & Smith S. (2008). Australian autism handbook. Edgecliff, NSW: Jane Curry Publishing.
Volkmar, F. R., & Wiesner, L. A. (2009). A practical guide to autism. What every parent, family member and teacher needs to know. Hoboken, NJ: John Wiley & Sons.
1MacDermott, S., Williams, K., Ridley, G., Glasson, E., & Wray, J. (2007). The prevalence of autism in Australia. Can it be established from existing data? Report for the Australian Advisory Board on Autism Spectrum Disorders.
2 http://www.cdc.gov/ncbddd/autism/data.html#prevalence
3 http://www.autismspeaks.org/index.php
4 Lovaas, O.I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55,3-9.
5 Dawson, G. et al., (2010). Randomized controlled trial of an intervention for toddlers with autism: The Early Start Denver Model. Pediatrics, 125, e17-e23.
6 http://raisingchildren.net.au/
7 http://www.earlydays.net.au/
8 http://www.autismtraining.com.au/public/index.cfm?returnTo=%2Findex%2Ecfm
Article written by Amanda Richdale, PhD, MAPS, Associate Professor / Principal Research Fellow, Olga Tennison Autism Research Centre, School of Psychological Science, La Trobe University http://www.latrobe.edu.au/otarc/