Autism

Autism is a complex neurodevelopmental condition and causing behaviour that is rigid and repetitive. Other commonly observed symptoms are impaired communication and language skills, and somewhat inadequate social interactions.

The incidence of autism is common – a study revealed a reported rate of about 7 in every 10,000 people. Ratios between males and females can vary between 2:1 and 4:1 depending on whether the condition is moderate or severe. The rate of occurrence of autism in siblings can be between 3 and 7 percent.

Given the wide range of visible symptoms of autism, and the fact that there are varying degrees that they occur in, the term ‘Autism Spectrum’ was coined to include the wide range of symptoms better. Various conditions that are included within the autistic spectrum include: 

• Asperger’s syndrome 
  This condition is autism in possibly its mildest form. People with Asperger’s syndrome can manage their day to day life and can be very intelligent. They have specific areas of interest and can work on or discuss these for long spells without being distracted or suffering fatigue. Their social skills, however, are hampered to a greater extent.
   
• Pervasive development disorder
  This term is used to describe persons whose symptoms are more severe than those of Asperger’s syndrome, but less severe than the Autistic Disorder.
   
• Autistic disorder
  While there are no differentiated symptoms, the severity of the symptoms is more pronounced and intense. 
   
• Childhood disintegrative disorder
  This form of the disorder is rarest. Children who have this form of autism usually appear normal initially, and they tend to rapidly lose faculties, including motor, language, social and mental skills. This degeneration occurs mostly between the ages of 2 and 4. The occurrence of seizures is not uncommon.

The symptoms of autism are most commonly identifiable before the ages of three (perhaps due to the fact that the greatest milestones are achieved at this age). In children, the most easily identifiable signs are connected with attentiveness, processing sensory information, and learning. The signs and symptoms that are observed in children are also seen in adults Due to a range of possible disorders that exist in the autism spectrum, the range of visible symptoms is vast and in varying degrees. Here are common symptoms seen in autism: 

Communication
It is common for up to 40% of children with autism to not talk at all, while between 25 and 30% of children develop some language skill initially which is lost later. Some children may, however, have delayed speech. Here are some other easily visible symptoms of communication in children within the autism spectrum:

• A flat, monotonous voice lacking any intonation. Alternately, children may develop a singsong way of communicating messages.
• Inability to understand and respond to humour and sarcasm.
• An absence of empathy and warmth in communication.
• Inadequate responses to environmental stimuli, including responding to one’s name or being called. Another sign is the inability to recognize the voice of the parent or caregiver.
• Repetition of the same phrases or words, mostly without context.
• The absence of, or reduced use of gestures when communicating (in some cases, children only use gestures and do not speak to communicate their messages).

Behaviour
There is a distinct peculiarity or unusual pattern of behaviour with such children. Some commonly observed patterns include rocking, flapping of the hands, or a certain sound repeatedly, sometimes for hours at end. 

• Formation of an early attachment to an object which in time tends to become a fixation. While this may be normal even among other children who have their pet stuffed animal or blanket, those within the autism spectrum are usually seen preferring items that are harder, including keys and pens.
• Routines become extremely important. Children on the spectrum need a certain predictability around their tasks, and any deviation from routine environments or habits becomes extremely disturbing for them.
• Tasks must be explained individually. Children on the autistic spectrum find it hard to mimic or follow the lead of others. It also becomes more difficult for them to learn socially or ideate. They only respond to specific, concrete instructions.
• Attention spans are markedly low. Such children are also highly impulsive and tend to be clumsy when performing tasks.
• They tend to be very sensitive to touch and sound, and also to harsh light. Since they are not very socially adaptable and do not respond adequately to affection, they may be averse to being held, or to any friendly gestures like a pat on the back or holding their hand.

Social skills and interactions

Given that social skills are evident only once a child is about two years old, these are some signals that are noticed by parents only much later.

• People on the autistic spectrum prefer being on their own and do not make friends easily. Even when making associations, they do not recognize or reciprocate affection and warmth. They can continue playing the same game or engaging in the same activity for hours, and work best with tasks that are structured and require little ideation like sorting, working with blocks and lining up objects.
• They avoid eye contact or expression of any emotions, both positive and negative.
• Aside from expressing feelings, these children are also unable to comprehend or relate to the feelings expressed by others. They fail to recognize cues including body language and tone of voice.
• Questions asked are usually responded to in one word or a simple phrase. There is a possibility that the child may simply repeat what has been said in response to being asked or directed to do.

Regression
Regression is a condition common among children in the autistic spectrum. Children begin by developing speech and then suddenly stop talking. This most commonly happens around the age of 15 to 24 months. The difference in development and regression may also be seen in their social skills.

It is extremely difficult to study and classify autism because it is hard to find two people with exactly the same set and degree of symptoms. Due to the varied spectrum and the possible combination of factors contributing to autism, pinning autism down to one cause is impossible.

Causes

• Genetic
  There are over 100 genes that contribute to different factors and attributes, including autism. Extensive studies conducted over the last few decades indicate that genes are the most likely one of the contributing factors towards autism. The role of genes is not confined to merely causing autism, but also to several kinds of disorders like Rett’s Syndrome and the Fragile X syndrome. Genes may sometimes determine how the cells communicate or influence the severity of autism in individuals. In some people, the genetic mutation may be inherited from the parent, while in others it occurs as a new mutation in the child directly.
   
• Environmental
  There has been no conclusive evidence to show that environmental factors impact autism. What has been found, however, is that exposure to certain pollutants or drugs can cause autism in cases where the fetus is more prone to genetic mutation. In other studies, however, it has also been found that even with the same experience and the incidence of susceptible genes, some may not fall within the autistic spectrum.
   
• Others
  Other factors that may cause autism include overgrowth in the brain, metabolic problems, problems in the immune system and problems in brain connections.

Risk Factors
Some of the most significant risk factors include:

• Age of Parents
  Older parents have been shown to have a greater risk of having a child with autism. 
   
• Family history
  Children are more likely to be born with the disorder when the elder sibling has autism. In cases where the parents are not in the autistic spectrum, it may be possible to notice a minor symptom such as communication or social skill problems. 
   
• Gender
  Males have a greater chance of developing autism than females. The risk for boys is about four times higher than for girls.
   
• Preterm Babies
  Children are at greater risk of developing autism if they are born before 26 weeks of pregnancy.

Autism as a condition cannot be prevented. Being mindful of the contributors and the risk factors helps in minimizing the risk of autism. Following a healthy lifestyle before and during pregnancy, including timely medication can help improve the chances of protecting against autism.

Diagnosis of autism doesn’t rely on blood tests and scans. The parents and pediatrician, play a crucial role in an early diagnosis. The first sign to be watched out for is the timely progression of developmental milestones. Signs watched for include when the baby first smiled if the baby babbles and makes sounds, the presence of repetitive behaviours, whether eye contact is maintained, and whether the baby is moody or irritable. 
If there are significant delays or changes in reaching milestones, the parents need to report them to the pediatrician who may thereafter refer the child to a specialist for evaluation. Specialist, who may be a developmental pediatrician or a pediatric neurologist will run the child through a series of screening test which may include:

• Modified checklist for Autism in toddlers
  This is a tool which checks for the level of risk of the child for autism. It contains a series of questions which need to be answered by the parents. Every question has either a ‘yes’ or ‘no’ response. In cases where there is a high negative rate, a diagnostic evaluation is then sought.
   
• Diagnostic criteria for autism
  This is a screener which includes several criteria related to social interactions, communication, repetitive and stereotyped behaviours and delays and disturbances. The assessor usually has a benchmark of a minimum number of observable traits that qualify the child to be within the autistic spectrum.
   
• Conditions associated with autism
  This list provides a list of possible conditions that might be associated with autism, including motor impairments, epilepsy, and sensory processing disorder.

There is no treatment to reverse autism. The aim of all available treatment modalities is to minimize debility and maximize independence and potential of the individuals. Therapies are usually customized and used with those who have specific symptoms like epilepsy and hyperactivity along with autism.  
Since every individual in the autistic spectrum is different and has different needs, programs designed for them are personalized and must be with a defined structure. This customization becomes critical since most individuals in the autistic spectrum also display signs of other disorders like Attention Deficit Hyperactivity Disorder (ADHD).

It has been found that the earlier interventions begin, the sooner results are observed. It also takes far lesser time to bridge the gap between current levels of the individual and desired levels that are set. Treatments may focus on a combination of the following courses depending on the individual and his need:

• Behavioural management therapy
  This is a method which aims at reinforcing desirable behaviour and minimizing unwanted or unaccepted behaviour. A variety of tools are used to elicit and reinforce behaviour including pivotal response training and positive behaviour and support, to name a few.
   
• Cognitive Behaviour Therapy
  This form of therapy focuses on behaviour, thoughts and feelings and attempts to help the individual identify thoughts and behaviour that lead to problem situations or feelings. It helps them recognize emotions and cope with situations of anxiety.
   
• Joint Attention Therapy
  This is an important aspect of therapy since it focuses on interpersonal associations and interactions. This form of therapy has lasting results, which makes it very effective. Aspects focused on include communication and language and shared attention. Concepts worked on include pointing and shifting gaze between people and objects.
   
• Occupational Therapy
  Occupational therapy focuses on working with children’s abilities and needs with regard to going about and accomplishing regular tasks and daily routines. Therapists work on aspects like the child being able to dress and eat meals independently, personal care and communication, and other physical activities.
   
• Physical Therapy
  Since movement is a common problem faced by those in the autism spectrum, most individuals receive physical therapy. This form helps in building strength and improving posture, and at enhancing motor skills. There is no conclusive evidence, however, that can prove that this therapy can make a significant difference to movement.
   
• Social Skill Training
  Social skill training emphasizes building behaviour of children and enabling them to experience more inclusive interactions. It stresses desirable patterns and reinforces them. Some skills include initiating conversations, handling teasing and showing sportsmanship.
   
• Speech-language Therapy
  This therapy focuses on both verbal and non-verbal communication to be able to experience normal interactions. The objective is to help individuals express their feelings in words, name objects, construct meaningful sentences and intonate better. It also includes allowing for more eye contact and gestures and being able to use sign language to communicate messages.
   
• Nutrition Therapy
  Nutritional advice is given in varied forms to individuals who have autism. Few of them really have scientific evidence backing them. The aim is to ensure that people with autism have a healthy and balanced diet and receive adequate nutrition. People with autism may have aversion to certain kinds of foods (soft and pulpy foods, for example). Often, people with autism tend to make psychological connections with food – associating them with nausea or pain. Some studies have indicated that people with autism tend to have thinner bones. Catering to such problems to ensure that there are no nutritional deficits becomes more important.
   
• Medication in autism
  There is no prescribed medication for autism per se. In some cases, a specialist may prescribe medicines for certain conditions which are symptomatic in autistic individuals. Antidepressants, anticonvulsants, anti-anxiety and stimulants for hyperactivity are some forms of medication that may be advised.
   
• A variety of other therapies have been combined and modified to suit the needs of the time. School-based therapy for curricular deficits, parent-mediated therapy and joint attention therapy are just some of them. However, the primary skill sets and behavioural issues that are dealt with remain largely the same.

Lifestyle management for Autism
Coping with autism in the initial years can be an exhausting task, for both the individual and family. Owing to the newness of the condition and its implications, the nature of the experience and its demands and the kind of assistance required, it can take a toll both physically and mentally. However, the key lies in being aggressive and timely in providing the right kind, and amounts of intervention at the earliest stages.

In managing autism, there are 2 major forms of management as follows:

• Educational management 
  In people who fall in the borderline or very low spectrum on the autistic spectrum, mainstream schooling may be a possible option. This helps in exposing children to bigger opportunities for other forms of learning including social interactions and mimicking as a learning tool. However, in people with severe autism, it is important to choose a special school that is equipped to handle such children and mould them to live relatively independent lives and reach their absolute potential. Working individually with children who have autism not only helps work on their concepts but also equips them to build on their strengths and give them avenues where they can explore possibilities and perhaps find a path for their future.
   
• Behavioural Management
  Autistic children thrive on predictability. A structured teaching method is, therefore, usually employed with them. This TEACH method works at building individual skills and the environment simultaneously. Through this method individuals help plan, organise and sequence their activities to plan better. Preparing for change, planning timetables and developing strategies that work with the individual are some primary objectives of behaviour management.

Managing the lifestyle of an individual with autism is a lifelong process. If there is early, timely intervention, individuals may be capable of leading independent lives as they grow into adulthood. Providing a positive and supportive environment can also help them lead more fulfilling lives. 

Prognosis
With time and continued intervention, most people with autism do experience a better quality of life. There are, however, three possible case scenarios for people in the autistic spectrum:

• Worsening of the condition
  Most commonly experienced among those with severe mental retardation. This forms the smallest percentage of the autistic population.
   
• Stable condition
  Among a more sizeable number whose life does not improve significantly, but does not deteriorate either.
   
• Improved condition
  Seen in the largest number of cases, where teens and adults are able to progress and live better lives on several levels.

While many of these scenarios may be possible, what stands, without doubt, is that those with autism will continue to require the additional support and professional assistance.

Complications
There can be some related conditions experienced by those who have autism. Mental health, characterized by anxiety disorders, mood swings, and depression are among the complications experienced. Seizures can also be experienced, usually beginning during teenage.