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Could this patient in front of me be manifesting Autistic Spectrum Disorder?

As a Doctor you can expect to come across children and adults with Autistic Spectrum Disorder (ASD).

Should you feel that you are not wholly confident as regards your knowledge and understanding of this disorder, we would like to offer you this brochure for your reference and referral.

The detection of children with Autistic Spectrum Disorder, in their formative years is vital. As a Doctor you are an important role player in this essential early detection.

Autistic Spectrum Disorder is the result of disordered brain development and function, NOT a psychological or emotional disorder. It is not the result of bad parenting and children with Autistic Spectrum Disorder do not choose to misbehave.

Autistic Spectrum Disorder is a complex, pervasive developmental disability, which seems to stem from a multi-factorial origin and causes disturbances in the brain. Estimates of prevalence vary greatly. Recent small scale, but intensive studies give higher numbers than earlier ones, this being due to the criteria for autistic disorders having been considerably widened over the years. The highest estimates for the whole spectrum, range from around 40 to around 90 per 10 000 births, but the true figures are still being investigated. ASD affects 4 times as many boys as girls. Of all the developmental disorders, ASD is the most researched and validated syndrome.

The onset of ASD is from birth or before the age of 3 years. Various subgroups are referred to within the autistic spectrum disorders. The ICD 10 system (International Classification of Diseases, 10th edition, World Health Organisation, 1992) and the DSM IV (Diagnostic and Statistical Manual, 4th Edition, American Psychiatric Association, 1994) suggest some subgroups, the best known of which are “childhood autism / early infantile autism” and “Asperger Syndrome” There is a fair amount of academic argument concerning the criteria differentiating these subgroups. However, in clinical practice, the most helpful approach to diagnosis is to establish if the child or adult concerned, has an autistic spectrum disorder and then to provide information concerning their present level of varying abilities. This type of detail is far more useful for identifying a person’s needs, rather than just putting him or her on a diagnostic subgroup.

Although children and adults with ASD present with many different levels of severity and also display a wide range of individual characteristics, they are all affected by the “Triad of Impairments”.

In addition to this Triad of Impairments, you may well observe the following additional features:-

  • Little or no eye contact;
  • No real fear of dangers;
  • Abnormalities in the development of cognitive skills, e.g. poor learning skills or resistance to normal teaching methods;
  • Abnormalities of posture and motor behaviour, e.g. poor balance;
  • Poor gross and fine motor skills in some learners;
  • Odd responses to sensory input, e.g. covering of ears;
  • Sense of touch, taste, sight, hearing and/or smell may be heightened or lowered;
  • Bizarre eating patterns - food fads;
  • Unusually high pain threshold;
  • Crying or laughing for no apparent reason;
  • Self-injurious behaviour, e.g. head banging, scratching, biting;
  • Abnormal sleep pattern.


Children and adults with ASD usually have accompanying learning difficulties. The range of intellectual abilities amongst children with ASD is vast.

The presence of additional disorders such as epilepsy, sensory and intellectual impairments can co-exist with ASD.

Remember that ASD can vary widely and there is no single feature that, if not present, excludes the possibility of Autistic Spectrum Disorder.

Diagnosis

The two internationally used systems of diagnosis and classification are the DSM IV and the ICD 10.


Problems of Diagnosis

It is imperative to distinguish Autistic Spectrum Disorder from the other disabilities such as hearing, visual, cognitive, other psychiatric and psychological disabilities. Differences between ASD and other primarily intellectual disabilities can be overlooked.

Compared to the pattern found in generalised developmental delay, where all areas of development are affected, the individual with ASD displays impairments in the timing, rate and sequence of many basic psychological, as well as cognitive developmental functions. Severe qualitative impairments for any stage of development are usually present.

The difficulties in diagnosis experienced by clinicians arise mainly because of the following reasons:-

  1. Variation in manifestation of features. The manifestations of the diagnostic criteria vary widely.

  2. Differentiation from other conditions. Language impairments resembling those in specific disorders of language development, or poor co-ordination as in dyspraxia, may be diagnosed, but the presence of the triad of impairments may be overlooked.

  3. Other conditions that can occur together with ASD, can disguise the triad of impairments, which can go completely undetected. This can also happen with adults contacting psychiatric services, who have never been diagnosed with ASD. It is particularly likely to happen with those who are more verbal and more able.

  4. Confusion with sub-groups, such as Childhood Autism, or Asperger Syndrome. It is much more important for the clinicians to diagnose the presence of ASD, than to worry about the sub-group. Specifically qualified assessment teams can evaluate this issue.

  5. Relying on the observation of the child
  6. In structured situations and in a limited time frame, an individual with ASD may show no obvious signs of “autistic behaviour” and subtle signs can be missed.

  7. Blaming the parents
  8. The social impairment in ASD is, in most cases, present from birth or early life. This often leads to difficulties in the parent-child relationship. Clinicians, understandably, are prone to look for psychopathology in the parents, whenever they see a child with “behaviour” problems who look physically normal. When they see how poorly the child interacts with the parents, they then take this as corroboration of their diagnosis.


The Process of Diagnosis

The pitfalls described above can only be avoided if the clinician bears in mind the possibility of ASD, when faced with a worried or puzzled parent describing odd behaviour in their child.

ASD is a developmental disability caused by chemical dysfunction in the brain. The pattern of abnormal behaviour unfolds over time. The correct diagnosis can be made only by taking a detailed developmental history from infancy and obtaining equally detailed information concerning behaviour in different settings and at different ages.

A definite diagnosis cannot be made by briefly observing or testing the child in the doctor’s room. Observation should be performed by people specialising in the field of ASD and over an extended time frame, in varying situations.

The initial apparent absence of the typical discrepant pattern, does not rule out a possible diagnosis of ASD.

We suggest that if you suspect that ASD is the diagnosis, you mention this to the parents as a possibility and that you would like to refer the patient to a diagnostic team who specialise in the field of ASD.


International Organisations involved with Autistic Spectrum Disorder:-

National Autistic Society - United Kingdom
393 City Road. London EC1V 1NE. England. Tel: 0944 20 7833 2299 Fax: 0944 20 7833 9666; E-mail: nas@nas.org.uk; Website: http://www.oneworld.org/autism_uk/

Autism Society of America
7910 Woodmont Avenue. Suite 650. BETHESDA. MD 20814. USA. Tel: 091 800 328 8476. Fax: 091 301 657 0869. Website: http://www.autism-society.org/

Autism Research Institute
4182 Adams Avenue. SAN DIEGO. CA 92116 ; USA Tel: 091 619 281 7165. Fax: 091 619 563 6840 ;Web site: http://www.autism.com/ari


Recommended Publications:
  1. Lorna Wing - The Autism Spectrum: A guide for Parents and Professionals. Highly recommended.Published by Constable, 1996.

  2. Lorna Wing - Autistic Spectrum Disorders: An Aid to Diagnosis.Gives a good insight into the criteria for diagnosis of autism. Published by The UK National Autistic Society, 1993.

  3. Uta Frith - Autism: explaining the enigma Published by Oxford: Blackwell, 1989

  4. Edited by Eric Schopler & Gary Mesibov - Neurobiological issues in autism Published: New York: Plenum, 1987

  5. Edited by Christopher Gilberg. Diagnosis and treatment of autism

  6. Maureen Aarons & Tessa Gittens. The autistic continuum: an assessment and intervention schedule for investigating the behaviours, skills and needs of children with autism or autistic spectrum difficulties.Published: Windsor: NFER-Nelson, 1992

  7. Edited by Eric Schopler & Gary Mesibov - The effects of autism on the family Published: New York: Plenum, 1984

  8. Tony Attwood - Asperger’s Syndrome. A Guide for Parents and Professionals. Published by Jessica Kingsley Publishers, 1998.

  9. Lorna Wing - Asperger’s Syndrome: A Clinical Account. This book covers the topic of Asperger’s Syndrome from a more clinical viewpoint. Published by The Journal of Psychological Medicine, 1992.

  10. Edited by Eric Schopler & Gary Mesibov - High-functioning individuals with autism - New York: Plenum, 1992

All these books, plus many more and a wide range of papers and journals are available from the UK National Autistic Society (contact details previously provided).

Please refer to the Web Site addresses supplied above, of other international organisations, for additional reading material that is available.

A certain amount of material included in the brochure is chiefly taken from a paper written by Dr Lorna Wing, Consultant at the Centre for Social and Communication Disorders. It has been reproduced with the kind permission of Dr Lorna Wing and the National Autistic Society, United Kingdom, who published this paper in their quartley magazine, “Communication”, edition Winter 1998.


References:
  1. “Classification and diagnosis - looking at the complexities involved” - Dr Lorna Wing.
  2. “Communication” Winter 1998. - The National Autistic Society, England.
  3. The autistic spectrum - a parent’s guide. The National Autistic Society, England.
  4. Autism: Bibliography. A guide to books and videos. The National Autistic Society, England.
  5. The Autism Spectrum. A guide for Parents and Professionals. Dr Lorna Wing.
  6. Developing a Broad and Balanced Curriculum. Mrs Margaret M Golding. Autism The Way Forwards RSA. September 1998.
  7. Autism: How to help your young child Leicestershire County Council and Fosse Health Trust. ISBN 1 899280 65 0




Reprinted by permission of The Autism Societe of South Africa Jill Stacey
Note: The listing of resources is given on an information only basis. It is not to be construed as an endorsement by Puterakembara of any of the profesionals, treatments, opinions, publications or products offered by those mentioned above




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