When To Consider Autism
Dr. Praveen Suman*
Consultant Developmental Pediatrician, Child development Clinic in Centre for Child Health, Sir Ganga Ram Hospital, New Delhi. Email: praveensuman@gmail.com *
What is Autism?
Autism is a complex developmental disability. It was first described by Kanner (1943). It is one of the most severe childhood neuropsychiatric condition. Typically it appears during the first three years of life. It has a triad of impairments.
  • Communication
  • Socialization
  • Imagination/activities

Autistic spectrum disorder
Autism is one of five disorders coming under the umbrella of Pervasive Developmental Disorders (PDD) which has been described by DSM IV.

Autistic Disorder
Asperger's Disorder
Childhood Disintegrative Disorder(CDD)
Rett's Disorder
PDD-Not Otherwise Specified
(PDD-NOS)
Prevalence of Autism
Prevalence of Autism is 2-6 cases per 1,000. It is growing at a rate of 10-17 percent per year. It is more commonly seen in boys (Boy: Girl 4:1). It's presentation is usually identified before 30 months. There is no difference in prevalence among different racial or socioeconomic population.
Theories
Various theories have been proposed to explain the etiology of autism. The common ones are:
  • The theory-of-mind deficit theory
  • The executive function deficit theory
  • The central coherence theory
Characteristics of Autism
Persons with autism may exhibit some of the following traits: They insist on sameness, there is a resistance to change. They have difficulty in expressing needs; use gestures or pointing instead of words. Autistic children often repeat words or phrases in place of normal, responsive language. Laughing, crying, showing distress for reasons nor apparent to others. These children prefers to be alone; They throw severe temper tantrums. They have difficulty in mixing with others. They may not want to cuddle or be cuddled. Autistic children give little or no eye contact. These children are unresponsive to normal teaching methods. They are often engaged in sustained odd play. For e.g., they like to spin objects. They have inappropriate attachments to objects e.g., paper, utensils. They show apparent over-sensitivity or under-sensitivity to pain. These children show no real fears of danger. Such children are observed with noticeable physical over-activity or extreme under-activity. They also have uneven gross/fine motor skills. Also they are not responsive to verbal cues; they acts as if deal although hearing tests in normal range.
Language Development
Children with Autism have delayed and deviant language. They have peculiar use of sounds and words. Presence of Echolalia is seen with the effected children, along with pronominal reversal that is they use 'i' where 'you' is meant and vice-versa e.g., 'do you want a drink' instead of 'i' want a drink'. They show a denial of personal identity (psychoanalysts) or just related to echoing. Use of '-ing' For e.g., 'daddy piping', 'boy bubbling' (boy blowing bubbles).
Social Development
They children show physical and emotional distance from others, they show failure to develop social attachments. They appear to have lack of co-operative group play. They have difficulties in reacting to or recognizing other people's feelings.
Intellectual Development
Children with autism show poor or verbal ability. These children may perform above average on memory or spatial tasks. Such children may be talented in things like music or drawing. Generally ¼ - 1/3 of the children have IQ>70.
Normal Development
Autism is a disorder in which there is a deviation from the normal development (communication, social and imaginative skills), thus it is important to know normal development in detail, before diagnosing a child with autism.
Diagnosis of Autism
No medical tests are required for diagnosing autism. It is important to diagnose these cases early so that early intervention can be instituted.
Red flag signs
HICHD lists these five behaviors that signal further evaluation is warranted:
  • Does not babble or coo by 12 months
  • Does not gesture (point, wave, grasp) by 12 months
  • Does not say single words by 16 months
  • Does not say two-word phrases on his or her own by 24 months
  • Has any loss of any language or social skill at any age
Diagnostic tools
They are several screening tests that are now used in diagnosing autism they are:
  • CARS rating system (Childhood Autism Rating Scale)
  • The Checklist for Autism in Toddlers (CHAT)
  • Modified CHAT (M-CHAT)
  • The Autism Screening Questionnaire

The diagnosis of autism is based on the criteria given by DSM IV.
A total of six (or more) items from (A), (B), and (C), with at least two from (A), and one each from (B) and (C):

(A) Qualitative impairment in social interaction, as manifested by at least two of the following:
  • Marked impairments in the use of multiple non-verbal behaviors such as eye-to-eye gaze, facial expression, body posture 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 to other people).
  • Lack of social or emotional reciprocity (note: in the description, it gives the following as examples: not actively participating in simple social play or games, preferring solitary activities or involving others in activities only as tools or "mechanical" aids).

(B) 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.

(C) Restricted repetitive and stereotyped patterns of behavior, interests and activities, as manifested by at least two 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, nonfunctional 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.

(II) Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years:

A. Social interaction
B. Language as used in social communication
C. Symbolic or imaginative play

(III) The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder.
Table - For convenience the normal cognitive, communication and social skills are given below
Indicators of Normal Development
Age Skills Age or Abilities Awareness and Thinking Communication Movement Social Self-help >
Birth 3 months Responds to new sounds. Follows movement of hands with eyes. Looks at object and people. Coos and makes sounds. Smiles at mother's voice. Waves hands and feet. Grasps objects. Watches movement of own hands. Enjoys being tickled and held. Makes brief eye contact during feeding. Opens mouth to bottle or breast and sucks.
3-6 months Recognizes mother. Reaches for things. Turns head to sounds and voices. Begins babbling. Imitates sounds Varies cry Lifts head and chest. Bangs objects in play. Notices strangers and new places. Expresses pleasure or displeasure. Likes physical play. Eats baby food from spoon. Reaches for and holds bottle.
6-9 months Imitates simple gestures. Responds to name. Makes nonsense syllables like gaga. Uses voice to get attention Crawls Stands by holding on to things. Claps hands. Moves objects from one hand to the other. Plays peek-a-boo, Enjoys other children. Understands social signals like smiles or harsh tones. Chews Drink from a cup with help.
9-12 months Plays simple games. Moves to reach desired objects. Looks at pictures in books Waves bye-bye. Stops when told "no" Imitates new words. Walks holding on to furniture. Deliberately lets go of an object. Makes markers with a pencil or crayon. Laughs aloud during play. Shows preference for one toy over another. Responds to adult's change in mood. Feeds self with fingers Drinks from cup.
12-18 months Imitates unfamiliar sounds and gestures. Points to a desired object. Shakes head to mean "no". Begins using words. Follows simple commands. Creeps upstairs and downstairs. Walks along Stacks blocks. Repeats a performance laughed at. Shows emotions like fear or anger. Returns a kiss or hug. Moves to help in dressing. Indicates wet diaper.
18-24 months Identifies parts of own body. Attends to nursery rhymes. Points to pictures in books Uses two words to describe actions. Refers to self by name. Jumps in place. Pushes and pulls objects. Turns pages of book one by one. Uses fingers and thumb. Cries a bit when parents leave. Becomes easily frustrated. Pays attention to other children. Zips. Removes clothes without help. Unwraps things.
24-36 months Matches shapes and objects. Enjoys picture books. Recognizes self in mirror. Counts to ten. Joins in songs and rhythm. Uses three word phrases. Uses simple pronouns. Follows two instructions at a time. Kicks and throws ball. Runs and jumps. Draws straight lines Strings beads. Pretends and plays make believe. Avoids dangerous situations. Initiates play. Attempts to take turns. Feeds self with spoon. Uses toilet with some help.
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