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How to recognize autism in your child

Only two to three decades ago, very few people knew, or had even heard, the word “autism”. Conversely, today, you will see or hear about autism, often from numerous media sources including: TV programs, newspapers, magazines, and the internet; however, not everyone has a real understanding about this condition. The goal of this article is to introduce and provide information about autism – when to think of it and what you can do to determine if your child has autism.

What is autism and what is the cause?

Autism, also called Autistic Spectrum Disorder (ASD), and is a common neurodevelopmental disorders (the same category with ADHD, learning disabilities, and other developmental disorders). The term “neurodevelopmental disorder” means that this abnormal condition creates a key problem in the developing brain, and causes delayed or deviate patterns of a child’s developmental skills, for example motor, language, learning, or social skills.

Autism has three core features: difficulties in social interaction, communication skill problems, and restrictive, repetitive behaviors and interests. Large numbers of current scientific evidence points out that autism is caused by multiple factors, mainly genetic and epigenetic, and including environmental factors. This means that children with autism had genes that cause this condition “before” they were born. Child rearing, vaccines, and nutrition do not cause autism.  

How big is the problem?

Currently, although the prevalence of ASD differs in different countries and ethnicities, it can be said that the average incidence globally is one in 150 children. Moreover, since genetic factors play an important role, it makes sense that we see a higher rate of autism in an autistic child’s family. The chance of an autistic child’s siblings having Autism is about 10 times higher than kids who do not have autistic siblings.

How is autism diagnosed?

Unlike other illnesses, autism and most other neurodevelopmental disorders cannot be tested for by physical exam, x-rays, or blood tests. Autism and many other disorders have to be diagnosed via intensive behavioral observation following standard criteria, with standardized methods, by qualified healthcare professionals such as developmental-behavioral pediatricians, child and adolescent psychiatrists, and child clinical psychologists.

The well-established standard criteria manual for neurodevelopmental disorders, including autism, is the Diagnostic and Statistical Manual (DSM), which had been developed by groups of specialists, using currently available scientific evidence. The latest publication is the DSM-V (the fifth edition). Therefore, now doctors and healthcare professionals will diagnose autism spectrum disorder according to the newest diagnostic criteria.

The DSM-V criteria for autism spectrum disorder requires two defined core symptoms – the first of which is persistent deficits in social communication and social interaction across multiple contexts and the second is a demonstrated restricted and repetitive pattern of behaviors, interests or activities[1]. The detail of criteria can be found in the website link noted below.

How do I know if my child has autism?

Signs of autism can emerge at different ages, depending on severity and pattern of each child. The statement “No two autistic children are the same”, is exactly true. The clinical presentation varies, which is the reason this condition is called “autism spectrum disorder”. However, many warning signs can alert you that something is not right; these signs may appear as early as in the first year of life.

Autism warning signs in first few years of life

Core symptoms of difficulty in social interactions and language skills might be seen in the first few months of life. Autistic children might not like being held or cuddled, then may look away when you want to make eye contact; they may lie alone quietly for hours, not crying for attention which is very abnormal for this age. These children might not show appropriate facial expressions, such as social smiles or laughing when being tickled. Another red flag is that they do not response to their own names or may seem not to hear when others talk to them. These behaviors may misguidedly cause their parents to think that their child has a hearing problem. One difference between a hearing problem and autism is that children with autism will respond (and are even very sensitive) to other sounds, such as vehicles, air conditioners, engines or television.

Another important core symptom is delayed or abnormal language development. While most children will begin saying “mama” and “dada” to parents around nine months old, and will use their first meaningful word around their first birthday, or minimally before 18 months; children with autism often start talking late or have difficulty with speech altogether. Autistic children have varying degrees of trouble communicating with others and may say words that have no meaning (like they are making up their own language). Some autistic children repeat words that they hear often, but that they don’t understand, such as sentences or songs in advertisements.

Conversely, some children with less severe autism (previously defined as Asperger’s syndrome) may show normal language milestones, but may use language inappropriately, such as speaking like adult, and are often called “little professor”. Children with autism also have limited and restrictive interests and they may talk about the same topic (for example, dinosaurs) over and over again, and refuse to talk about other things.

Regression of language can be seen in about 25% of children with autism. Some children can say a few meaningful words or call “daddy”, “mommy” or even have normal eye contact before they stop talking and lose interest in other human beings. This phenomenon usually happens between 12 and 18 months, and then is misdiagnosed as being caused by the MMR vaccine, which usually is given at 12-months of age. However, autism is not the only cause of developmental milestone regression. This regression could be the sign of some serious disease, such as mitochondrial disease  or other neurological problems. Therefore, if your child shows regression of some developmental skills, such as ceasing to talk, waving goodbye, or responding to their names, and paying less attention to others, you should bring them in to have a full assessment with a specialist.

Warning signs of autism in older children

Deficits in Social Interactions and Communications Skills:

There may be a lack of eye contact, lack of verbal communication, and lack of response.

Children with autism usually avoid making eye contact with people. They seem not show interests in their peers. Sometimes they prefer to talk or play with older kids or adults. They do not communicate their needs in typical ways, for example, pointing to the thing they want. They might have tantrums until they get what they want, or pull someone’s hand to grab it for them. They do not share their attention with others; for example, if you show them something interesting by pointing to it, they will not look at the thing you point to.

They have difficulty understanding body language, facial expressions, emotions and feelings of other people. This skill is called “Theory of mind”, and develops on its own in ‘normally’ progressing children. The difficulty of predicting or understanding others’ thoughts and feelings in children with autism is usually called “mind-blindness”, which causes them huge problems when they need to socialize with their peers. Some children with autism may desire to play with others, but they do not know how to play appropriately and might scare other kids away. Children who can communicate, may talk inappropriately or be too straightforward; for example, they may say something like “you are so fat like a pig” right in front of your face and they are not aware that it will hurt your feelings.  Many people may think that these children are simply are rude and ill-behaved; so, it is not a big surprise that they may prefer to be “aloof” or live in their own world.

Restrictive and Repetitive Behaviors and Interests:

Repetitive behaviors are usually seen in younger children; for example, hand flapping, finger flicking and body rocking or they might stare at some object for hours. These behaviors are thought to be the way they self-soothe when they are over or under sensitized. Autistic children can be either extremely sensitive or not sensitive at all to their own pain or that of others or their surroundings and emotions. For example, they may not cry at all when they feel pain, but they may cry and react unusually to new sights, smells, textures and sounds. When they grow up, these behaviors usually fade away, but can persist in severe cases or in the case of intellectual disabilities.

Restrictive interests and fixed routines are very common in children with autism. They are very sensitive to changes. Changes make them feel uncomfortable, so they prefer to have the same daily routine, in the same environment, with the same people. Changing one of their routines can cause excessive crying or unstoppable tantrums. They may insist on following a rigid routine, eating the same foods from the same plate, sitting on the same chair. Their interests are also very narrow. They can play with dinosaurs or blocks all day, even if they have lots of toys nearby. Some children may have very high levels of intellect for their age, and be able to do things like memorize the names of dinosaurs or all the different bus routes, depending on their topic of interest.

What should I do, if I think my child could have Autism?

Whenever you suspect that your child has autism, you should bring them to see a pediatrician as early as possible, because early detection will lead to early intervention (treatment) and the best outcome for your child. You should trust your own instincts, because you know your child best. If you feel that something is wrong with your kid(s), even if everyone around you says that there is nothing wrong, it is worth it to see a specialist for the proper assessments. Additionally, there are a few standardized diagnostic screening questionnaires available free online for parents to be able to get some idea of what is happening before bringing kids to see their pediatrician. Two examples include the Modified Checklist for Autism in Toddlers (M-CHAT) [2] and the Autism Quotient (AQ) [3].

It is still very important for you to bring your kids to see a pediatrician regularly to check their developmental milestones, whether you suspect autism or not. The standard recommendation from the American Academy of Pediatrics and The Royal College of Pediatricians of Thailand, is that every child should be assessed for their development by standardized screening tools, at the ages of nine months, 18 months, and 24 to 30 months old.  These recommendations give children the earliest possible likelihood of diagnosis of developmental problems and most effective treatments, for the best outcome. For autism, the early signs can be seen by the 9-month visit. If there is no sign at that point, the 18-month old visit will be a cornerstone for detecting of autism.

What is the treatment? Is it curable?

There is no cure for autism, but early intervention can help.

Early intervention is the umbrella term for therapies and training that help kids with special needs, such as developmental delays, autism and intellectual disabilities, to improve their difficulties and reach their potential. Early intervention is the key to success for children with autism. The main treatment for autism consists of behavioral and communication approach, for example, speech therapy, occupational therapy, social skill training, and special education.

Behavioral and communication approach

These therapies help children with autism to be able to communicate with others, to indicate their needs and to understand other people’s thoughts and feelings. Restrictive behaviors and interests which disturb children’s social functions and daily living should also be eliminated as much as possible. There are many techniques and methods approved for children with autism, for example, Applied Behavioral Analysis (ABA)[4], DIR (Developmental, Individual-differences, & Relationship-based model) or “Floor time”[5], and the Early Start Denver Model (ESDM)[6]. Because every child has their own strengths and weaknesses, there is no single solution for therapy that works for all children. The best solution should be designed depending on each child’s symptoms. The treatment plan might be changed as the child develops and changes. Early intervention and regular reassessment are the keys for of best outcome.

Medications

There is no medication for core symptoms of autism. However, medications may be necessary in some kids who have problematic behaviors, such as aggression, mood problems, or hyperactive behaviors, all of which negatively affect therapy.

Long-term Plan for Education or Self Care

When school age is reached and if social function is good enough, children with Autism should have chance to attend regular school classes, ideally with typical developing peers, so they can develop normal social skills. However, children with autism need regular monitoring and help from a multidisciplinary team, including school, physician, and family. If a child’s social function or cognitive level is not adequate for regular school, then special education in a special school or institute would be the next option. In some severe cases, they may need to live under supervision for life, and developing helpful daily life skills will be the main goal for this group.

Doctor to Parents

“I would like to send my message to parents of children with autism that this is a long tough journey. You may experience sadness, anger, disappointment, stress and ‘burnt-out’ feeling often. It is okay to feel that way, and it is okay to ask for help. Healthcare professionals, therapists, and teachers are willing to work with you and your child as a team. So please remember that ‘you are not alone.’”

Last but not least, the knowledge of autism has increased rapidly within the last 10 years. In fact, autism is one of the most studied and researched topic in brain-based behavior science and psychology research society at the moment. Please do not lose hope for cure or great progress; however, it is also necessary to educate yourself and keep your knowledge up-to-date from reliable sources of information. There are still those who believe that autism is caused from vaccines, despite of huge volume of scientific evidence that contradicts that claim [7]. There are many alternative treatments, so called “complementary alternative medicines” (CAM), for example, special diets, chelation (a treatment to remove heavy metals like lead from the body), biological agents (e.g., secretin), or body-based systems (like deep pressure). I would like to quote the recommendation from CDC (The Centers for Disease Control and Prevention), which address the current standpoint of healthcare professionals on CAM for Autism. 

“These types of treatments are very controversial. Current research shows that as many as one third of parents of children with an ASD may have tried complementary or alternative medicine treatments, and up to 10% may be using a potentially dangerous treatment.[4] Before starting such a treatment, check it out carefully, and talk to your child’s doctor”.[8]

References

  1. DSM-V criteria for Autism Spectrum Disorder (ASD).  Available from: http://www.cdc.gov/ncbddd/autism/hcp-dsm.html.
  2. Modified Checklist for Autism in Toddlers (M-CHAT). Available from http://www.m-chat.org.
  3. Autism quotient (AQ). Available from: http://www.autismresearchcentre.com.
  4. Applied Behavioral Analysis (ABA) http://www.lovaas.com/
  5. Floor time or DIR (Developmental, Individual-differences, & Relationship-based model) http://www.stanleygreenspan.com/
  6. Early Start Denver Model (ESDM) http://www.ucdmc.ucdavis.edu/mindinstitute/research/esdm/
  7. Autism fact for parents http://www2.aap.org/advocacy/releases/autismfactsforparents.pdf
  8. Autism spectrum disorder: treatment http://www.cdc.gov/ncbddd/autism/treatment.html  

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Nanthakorn Eu-ahsunthornwattana, M.D. Summary: Pediatrics Pediatrics