“I can’t change the direction of the wind, but I can adjust my sails to always reach my destination” said Jimmy Dean. In my opinion a similar mindset is required, if you wish to enable a child with ASD.
Autism Spectrum Disorder (ASD) is a condition that affects child’s performance or functioning. It is not caused by anyone. Children with ASD see, hear, think, learn, relate and perceive the world differently to others. Hence some of the greatest inventors, musicians, painters and sculptors this world has ever seen, have been attributed with ASD.
Every child with ASD has 3 major characteristics. They are:
1. Difficulties or deficits in social communication
2.Difficulties or deficits in social interaction
3.Restricted patterns of behaviour, interests and activities.
Yet, ASD is a very diverse and varied condition. While I have diagnosed twins and many siblings with ASD, I have not seen two children with ASD who were same. This is because the degree of impairment in communication, social interaction, learning and adaptive functioning, varies in each child.
Leo Kanner first described Autism in children in 1943. The term autism derives from the Greek word ‘autos’ means ‘self’. Autism literally means ‘alone’. But individuals with ASD are not lonely. Autism was included as part of a ‘Spectrum’, in the DSM-5 classification (Diagnostic and Statistical Manual-5), a diagnostic tool used in USA and around the world. ‘Autism’ and ‘Asperger syndrome’ are two well recognised prototypes of the ASD spectrum.
ASD is common. It is present in 1-2% of children. Some studies show prevalence to be as high as 1 in 40, while others report this to be as low as 1 in 400 children. Possible explanations for increase in ASD prevalence could be changes in the way it is diagnosed, increased awareness and viewing autism as a spectrum condition.
When can Autism Spectrum Disorder be diagnosed?
Symptoms of ASD are usually present by 18 to 24 months of age. Some children appear to achieve early language milestones, but then regress or plateau in their communication and social skills. In general, the more severe the impairments in social interaction and communication, the earlier they present. Some children present in school years when the social demands exceed their limited capacities. Currently, most children are diagnosed between the ages of 4-5 years.
In an interview with Fay McGill a Speech-Language Pathologist, she talks about traits or behaviours in young children for autism spectrum disorder.
Who can diagnose Autism Spectrum Disorder?
Diagnosis of ASD can be undertaken by a:
– Neurodevelopmental Paediatrician
– Community Paediatrician
– Psychologist or
– Child Psychiatrist.
Depending on the child’s needs and difficulties, following professionals may also be involved in the assessment:
– Speech and Language Therapist
– Child Psychologist
– Occupational Therapist
Why is it important for Autism Spectrum Disorder to be diagnosed early?
There is no cure for ASD. Nonetheless early diagnosis and intervention improves child’s behaviour, social functioning and communication. Evidence shows that interventions are more effective, the earlier they are commenced. In some children, with appropriate interventions the ASD symptoms can be reduced to an extent that they no longer impact child’s functioning and learning. Diagnosis if delayed, can lead to disengagement from learning, secondary mental health conditions such as depression and family breakdown. Evidence shows that the cost of lifelong care can be reduced by two-thirds with early diagnosis and intervention.
What are the main features of Autism Spectrum Disorder?
There are innumerable examples and attributes of ASD. I have listed below the more common ones, without being too fussy e.g. one can debate whether ‘preference to play alone’ should be under play, behaviour or social interaction?
Elliott H. Sherr, MD, PhD. Institute of Human Genetics talks about Differential Diagnosis of Autism Spectrum Disorder: A Neurologist’s Perspective that details out the investigation and treatments of ASD.
What are pointers to ASD?
– Lack of responsive smile by 3-6 months
– Not babbling by 10 months
– Lack of joint attention by 6-9 months
– Not responding to name by 10-12 months
– Not waving ‘bye-bye’ or giving affection by 14-16 months
– Not pointing to items of interest or object by 12-18 months
– Not enjoying sharing a book by 18-24 months
– Not obliging with simple requests e.g. ‘give me the spoon’, by 18-20 months
– Lack of Pretend play e.g. ‘pat-a-cake’, by 18-24 months
– No symbolic play e.g. ‘riding a broomstick for a horse’, by 30-36 months
– Not taking turns in play by 3-4 years
– Lack of imaginative play e.g. play with dolls, by 4 years
– Not joining in play with other children i.e. group play, by 4-5 years
What conditions can be present with Autism Spectrum Disorder ?
ASD is often accompanied with other neurodevelopmental conditions. These include:
– Learning disability (LD)
– Language impairment
– Anxiety (can be one of the main issues)
– ADHD (attention deficit hyperactivity disorder)
– ODD (oppositional defiant disorder)
– CB (challenging behaviours)
– Feeding difficulties
– Coordination difficulties (Dyspraxia)
Each of these condition(s) when present, could vary in severity. Some co-morbid conditions such as ADHD, Anxiety, LD and Language impairment can appear as ASD. Hence, the neurodevelopmental assessment needs to be detailed and thorough.
What to do? The next steps…
A medical diagnosis would avoid child being labelled with moral diagnoses such as ‘weird’, ‘difficult’ or ‘personality disorder’. A comprehensive, and individualised management plan can build up on the child’s strengths and address their unique needs.
Numerous behavioural, educational and environmental interventions can be implemented to address the above mentioned 3 characteristics of ASD. Medications can be used to treat symptoms of co-morbid conditions such as ADHD, Anxiety, sleeping difficulties. This can improve a child’s functioning and learning.
Diagnosing early helps parents and teachers to seek extra help at school through SEN support or EHCP (Education Health Care Plan). Having a diagnosis could help in long term planning, seeking help and support with respite and leisure services. A comprehensive diagnostic report could help in applying for disability living allowance (DLA), certain benefits and help with housing when required.
“Aerodynamically the bumblebee shouldn’t be able to fly, but the bumblebee doesn’t know that, so it goes on flying anyway” said Mary Kay Ash. With hope, perseverance and some hard work, what appears improbable with this diagnosis, can become possible.
1. American Psychiatric Association. Autism spectrum disorder. In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association, Arlington, VA 2013. p.50.
2. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders. Clinical descriptions and diagnostic guidelines.
3. Johnson CP, Myers SM, American Academy of Pediatrics Council on Children With Disabilities. Identification and evaluation of children with autism spectrum disorders. Pediatrics 2007; 120:1183.
4. Dover CJ, Le Couteur A. How to diagnose autism. Arch Dis Child 2007; 92:540.
5. National Institute for Health and Care Excellence. Autism spectrum disorder in under 19s: recognition, referral and diagnosis. Clinical guideline [CG128]. September 2011, updated December 2017..
6. Scottish Intercollegiate Guidelines Network (SIGN). Assessment, diagnosis and interventions for autism spectrum disorders. SIGN publication no. 145. June 2016.
7. Lai MC, Lombardo MV, Baron-Cohen S. Autism. Lancet 2014; 383:896.
8. Landa RJ, Holman KC, Garrett-Mayer E. Social and communication development in toddlers with early and later diagnosis of autism spectrum disorders. Arch Gen Psychiatry 2007; 64:853.
9. Ozonoff S, Iosif AM, Baguio F, et al. A prospective study of the emergence of early behavioral signs of autism. J Am Acad Child Adolesc Psychiatry 2010; 49:256.
10. Zwaigenbaum L, Penner M. Autism spectrum disorder: advances in diagnosis and evaluation. BMJ 2018; 361.
11. Lord C, Bishop SL. Recent advances in autism research as reflected in DSM-5 criteria for autism spectrum disorder. Annu Rev Clin Psychol 2015; 11:53.
12. Filipek PA, Accardo PJ, Ashwal S, et al. Practice parameter: screening and diagnosis of autism: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society. Neurology 2000; 55:468.
14. Gada S, Pervasive Developmental Disorders p106-117, Community Paediatrics, Oxford University Press, ISBN: 978 0 19 969695 6