Autism spectrum disorders: An overview

People with autism spectrum disorders (ASD) present with range of interrelated difficulties such as delays in language development, sensory sensitivities, difficulties in social communication and repetitive/ rigid behaviours and interests. Autism is best thought of as a spectrum of difficulties with people being affected very mildly on one end of the spectrum and very severely on the other.

Autistic spectrum disorders include Asperger syndrome: people with Asperger’s tend to have normal language development and are of normal intellectual ability or above. Many people with autism can present with special abilities and strengths in areas such as music, maths or computers.

PREVALENCE

Depending on how it is measured, autism spectrum disorders are thought to affect about 1 per cent of the population, with many more boys affected than girls (ratio is about 4:1). Since the 1980s, there has been a large increase in the diagnosis of these disorders, though it is not clear whether this is increased sensitivity of diagnosis or whether there is an actual increase in the prevalence.

As autism spectrum disorders are characterised by clusters of behavioural/communication problems, diagnosis is made by professional observation and judgment. Unlike medical conditions, there is no ‘blood test’ that determines if a person has ASD. Below is the formal diagnostic criteria from DSM-V, which guides professionals who make this judgment.

DSM-V

– Diagnostic Criteria for Autism Spectrum Disorder

A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive) 
1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions. 
2. Deficits in non-verbal communicative behaviours used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication. 
3. Deficits in developing, maintaining, and understand relationships, ranging, for example, from difficulties adjusting behaviour to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

B. Restricted, repetitive patterns of behaviour, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive) 
1. Stereotyped or repetitive motor movements, use of objects, or speech (eg simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualised patterns of verbal or non-verbal behaviour (eg extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).
3. Highly restricted, fixated interests that are abnormal in intensity or focus (eg strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (eg apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

CAUSES

While there is no one specific cause of autism spectrum disorders, there are several identified risk factors in the research literature. These risk factors include genetics, prenatal and perinatal factors, neuroanatomical abnormalities, and environmental factors. While it is possible to identify general risk factors, it is much more difficult to pinpoint specific factors in individual cases. For example, while you are 15 to 30 times more likely to be autistic if you have an autistic sibling, it is impossible to make specific predictions within a family. It is likely there is more than one gene at play which require interplay with specific environmental factors to result in autistic traits.

DIAGNOSIS AND TREATMENT

In young children, autism can be identified and diagnosed in the preschool years, while many of milder cases (such as Asperger’s) are not being identified until late into primary school and even later. Indeed, in recent times many people are being diagnosed as adults. Diagnosis is best made after multi-disciplinary assessment with a qualified mental health or specialist autism service.

There are many specific treatment approaches that are helpful in managing autistic spectrum disorders. While there is no ‘cure’, there are many treatment and educational approaches that have been proven to reduce the difficulties associated with autism. The goal is to help the individual learn specific social and communication skills and to move to the lighter end of the spectrum. Treatment or educational programmes should always be tailored to the individual and their specific needs. Treatment approaches that can help are:

1. Special structured educational programmes These can include Applied Behavioural Analysis (ABA), Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH) or other eclectic educational approaches that target the specific needs of children with autism.

2. Speech and language therapy One of main difficulties facing people with autistic spectrum difficulties is language and communication. This can be overt language delay in the case of traditional autism or problems with social and pragmatic communication as in the case of Asperger's syndrome. Speech and language therapy targeting these difficulties can be of great benefit. In addition, there are many group-based parenting programmes specifically targeting autism that teach parents how to maximise their children's language and learning such as the 'More than Words' Hanen Programme.

3. Occupational therapy People with autism can have many sensory difficulties such as hypersensitivity to certain types of touch or sound or contexts that can cause them great problems. For example, a child might find the noisy situation of a busy playground over-whelming and this can precipitate a serious tantrum. Through occupational therapy, parents and children can be taught different ways to manage these situations and to learn how to self-regulate when upset.

4. Social skills training One the main stresses for people with autism is particular difficulties in approaching social situations and managing the many challenges of social communication. Social skills training, particularly for older children and teenagers, can be of great benefit. For example, instead of always talking too long to people about their own special interests, teenagers with AS can be taught how to first ask the other person about their interests and then how to listen to the responses.

5. Family education and support Raising a child with AS brings lots of extra challenges for parents. Parents have to manage increased behavioural problems, relationship difficulties between siblings, as well as managing a range of particular special needs. Family education and support through meeting other parents in similar situations can make a big difference. Parents can learn they are not alone and gain the support of others in learning how to cope. Specific behavioural parenting programmes which teach positive behaviour management ( such as the Parents Plus Programmes www.parentsplus.ie) can also help.

6. Nurturing a person's self-esteem and talents Finally, in the long term, the goal is to help people with ASD manage their difficulties and to learn to use their talents to contribute in work and to make meaningful relationships. People with ASD have special talents and interests which can be used productively in their lives and as a vehicle to connect with others. For example, many people with ASD might have a special gift for computers which they might use to gain employment or as a shared hobby with other friends.

USEFUL RESOURCES

www.tonyattwood.com.au ( website of Tony Attwood and author of The Complete Guide to Asperger's Syndrome)

www.templegrandin.com (the website of Temple Grandin who is a writer with autism who provides an excellent insight into the condition

www.autismireland.ie – Irish Autism Action

www.autism.ie – Irish society for Autism

www.aspireireland.ie – Asperger's Syndrome Association of Ireland

Dr John Sharry is a child and family psychotherapist