AUTISM SPECTRUM
DISORDERS
Autism spectrum disorders (ASD), also known as pervasive developmental disorders, are a group of mental health problems in children and adolescents characterized by severe impairments in several areas of development, including communication, social interaction, and range of interests and activities. Prevalence rates for ASDs are now estimated at about 1 in 110 children in the United States. The prevalence of children with ASD has now surpassed rates of children with well-known conditions such as cancer. For educational purposes, this means that most elementary schools with a population of 500 children will have 4 or 5 children with ASD. The greatest risk factor for ASD is being male with autism, occurring approximately four times more often in boys than girls. The pathophysiology of these pervasive developmental disorders is not known, but it is believed to be an inherited abnormality in the structure and function of certain parts of the brain, including those that govern the development of social relatedness and language.
The most severe of these disorders, autistic
disorder, is characterized by markedly abnormal development in
communication and social interaction and a markedly restricted range of
activity and interests. There may be a complete lack of language, or, if
language is present, it does not serve to initiate or sustain conversation with
others. There is severe impairment in the ability to form social relationships
and to understand others’ feelings. The child may not babble, point, smile, or
make meaningful gestures; he or she may have poor eye contact, may appear to be
hearing impaired, and may not know how to play with toys or engage in make believe play. The child often has very
restricted patterns of interest and may show little interest in the
environment. There may be inflexible routines that serve no function and
repetitive behaviors such as hand-flapping or body-twisting. To meet the
diagnosis, the disorder must have been present before age 3 years. Autistic
disorder is accompanied by intellectual disability in up to 60% of cases, and
seizures are often also present in the children who have intellectual
disability.
A less severe type of these
disorders, Asperger disorder, is characterized by all of the above
problems, without language impairment and intellectual disability. Children
with Asperger disorder who have stronger verbal skills are sometimes referred
to as sounding like little adults and struggle to pick up on the normal “give
and take of a conversation.” They often have very highly developed interest in
and knowledge about a narrow topic. To meet the diagnosis, there must be
impairment in the youth’s function at home, at school, or with peers. If some
of the above behaviors are present, but not enough to meet the diagnoses, the
disorder is called pervasive developmental
disorder, not otherwise specified.
Ideally, the evaluation should be
conducted by a multidisciplinary team of expert clinicians,
including a child psychologist, speech pathologist, and a medical professional
with developmental expertise (e.g., a child psychiatrist, developmental
behavioral pediatrician, neurodevelopmental pediatrician, or child
neurologist), in order to address essential aspects of the child’s
developmental skills. The evaluation for these diagnoses is complex, and requires input from multiple people
who know the child well. A diagnosis of ASD is based on descriptions of
behavior from interviews, questionnaires, and a direct behavioral examination.
Genetic testing is recommended because single-gene disorders or genetic
variations associated with autism are seen in ≈10%.
TREATMENT
The treatment of autism spectrum
disorders is aimed at enhancing the communication, social, and intellectual
development of the child through language and social skills therapies and
educational tutoring. The majority of these treatments are designed to take
place in the home or at school. There is no single best treatment package for
all children with ASD; however, early intervention
has been identified as very important for these children, and most individuals
with ASD respond well to highly structured, specialized programs.
If the child exhibits behaviors that
are aggressive, destructive, or self-injurious, medications (such as atypical
antipsychotics) may be helpful. Sometimes stimulant medication may be helpful
in reducing hyperactivity and impulsivity, and antidepressants may be helpful
in reducing compulsive behaviors.
COURSE
The autism spectrum disorders tend
to be lifelong problems. Children with these disorders who are identified
early, who have relatively intact language and intellectual abilities, and
receive intensive treatment have the
best outcomes.
