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Diagnostic Criteria for Autistic Disorder

1. A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3).
1. Qualitative impairment in social interaction, as manifested by at least two of the following
• Marked impairments in the use of multiple nonverbal behaviors such as eye to eye gaze, facial expression, body posture, and gestures to regulate social interaction.
• Failure to develop peer relationships appropriate to developmental level.
• A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people, (e.g., by a lack of showing bringing, or pointing out objects of interest to other people)
• Lack of social or emotional reciprocity (note: in the description, it gives the following as examples: not actively participating in simple social play or games, preferring solitary activities, or involving others in activities only as tools or “mechanical” aids)
2. Qualitative impairments in communication as manifested by at least one of the following:
• Delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
• In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others.
• Stereotyped and repetitive use of language or idiosyncratic language.
• Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level.
3. Restricted repetitive and stereotyped patterns of behavior, interests and activities, as manifested by at least two of the following:
• Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus.
• Apparently inflexible adherence to specific, nonfunctional routines or rituals.
• Stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole body movements)
• Persistent preoccupation with parts of objects.
2. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years:
1. Social interaction
2. Language as used in social communication
3. Symbolic or imaginative play
3. The disturbance is not better accounted for by Rett’s Disorder or Childhood Disintegrative Disorder

Symptoms of autism include impaired social interaction and language development along with a limited repertoire of interests. An autistic child is a mystery. Parents are puzzled and frustrated when their baby stiffens in their arms rather than cuddling, when he ignores them rather than clinging after they return from a weekend away. Instead of the exuberance that most children display during the first years of life, autistic children are curiously detached. They show little interest in language or in playing with other children; they do not maintain eye contact, and, even when they show attachment to their parents, they usually remain aloof to others.

Sometimes parents notice that something is wrong soon after the baby is born; more often, the symptoms become noticeable between 18 and 30 months, frequently when parents or doctors wonder why the child is not developing normal language or social skills. Some children may develop normally for awhile, then regress in their language and social skills. In any case, autistic disorder starts before age three and continues throughout life.

The disorder was first described and named by Leo Kanner in 1944, but it has troubled parents, teachers and doctors for centuries. In the not so distant past, autism was attributed to unresponsive or unloving parenting, but that theory has been discredited. Autism is now recognized as one of a group of developmental disorders involving abnormalities of brain structure and function. No one knows for sure what causes autism, but it has a strong genetic basis. If one identical twin is autistic, the other has about a 90% chance of being autistic.

About three-quarters of autistic persons are mentally retarded, usually with IQs in the range of 50 to 65. About 10% are autistic savants, with exceptional talents such as an encyclopedic memory, gifted musical or artistic ability or an ability to perform lightning-fast calculations. One autistic child with an IQ of 50, for example, could reel off every winning lottery combination for the past several years. Some autistic individuals have normal or even superior intelligence, but many of these cases may go undetected or dismissed as odd or eccentric behavior.

What Are the Signs

There are many variations of autistic behavior, depending in part on the patient’s level of intelligence. The essential features, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) “are the presence of markedly abnormal or impaired development in social interaction and communication and a markedly restricted repertoire of activity and interests.”

SOCIABILITY: As infants, autistic children don’t respond to parents’ interactive games such as pat-a-cake or peek-a-boo; as pre-schoolers, they don’t know how to play with other children. They also show little or no interest in creative play with dolls or stuffed animals.

While autistic children are capable of showing affection, it is usually on their terms. Some are painfully shy, anxious and fearful; others, fiercely independent and aloof. Nearly all seem more interested in objects than in persons; and sometimes their fascination is with an isolated part rather than the object itself. Autistic individuals generally have little insight into the subtleties of social interaction or what others are thinking or feeling. As children they usually have no interest in making friends; as adults, they may desire friends but lack the skills necessary for social interaction.

LANGUAGE, COMMUNICATION: Autistic children are usually delayed in acquiring language and many never gain more than rudimentary skills. Even those who develop a vocabulary and knowledge of grammatical structure usually struggle.

While there is no known cure, most autistic persons can be helped to make the best of their abilities with cadences, intonations and rhythms of human speech and lack the gestures to match what they are saying. When they speak, it is often in inappropriate or odd ways. When he wanted milk for example, one boy parroted back the question that had been asked of him: “Do you want some milk?” Another child repeated phrases or jingles non-stop in a high-pitched sing-song voice, but not in an effort to communicate. Autistic individuals who are not retarded may develop language skills, but they are seldom able to use them effectively for social interaction.

CHOICE OF ACTIVITIES: An autistic child’s pattern of activities is highly restricted and repetitive. He typically prefers to play by himself, usually in repetitive activities such as lining up objects in straight lines. One child spent several hours each day tearing cereal boxes into tiny shreds; another stared silently at a fish tank. Any attempt to change these routines would evoke a screaming tantrum, sometimes accompanied by biting and head-bumping.

While they may be able to amuse themselves for hours in solitary activities, most autistic children find it virtually impossible to get involved for long in a joint endeavor. They are stubbornly resistant to doing anything new or different even taking a different route to school or sitting in a different seat at the table. Ritualistic, repetitive behaviors, known as stereotypes, are common. These include hand flapping, rocking, humming, pacing, spinning, running in circles, spinning a string, tearing paper, drumming, flipping light switches and sometimes head-banging, biting or gouging. By adulthood, about one of three autistic individuals will have one or more epileptic seizures.

Most autistic persons require some degree of supervision and care throughout life, but about 10% can live independently. One autistic man with normal intelligence holds a research position at a university; others have corporate jobs that do not require interaction with the public.

What Can Be Done?

While there is no known cure, most autistic patients can be helped to make the best of their abilities. Parents must be educated about the nature of autism and guided by professionals on how to create an organized, predictable environment at home. They may be advised to set aside several short periods each day to help their child learn how to communicate through words and gestures. They must also work on eliminating problem behaviors and helping the child learn to interact with others. At home or in school, the task of educating an autistic child requires care, persistence and individual attention. Tasks or skills must be broken down into small steps that can be managed. Tantrums and repetitive behavior can be addressed gradually through behavioral therapy. Under the federal Individuals with Disabilities Education Act, autistic children over age three are eligible for education appropriate to their needs, based on an evaluation and an individual education plan. With support, some children can be mainstreamed in regular schools; others require specialized education in schools for autistic children or in private residential programs.

Although autism is believed to be related to abnormalities in neurotransmitters, no one medication has been found effective in treating the disorder. Some serotonin-enhancing drugs are helpful in controlling body movements and compulsive behavior. Anti-psychotic medications are sometimes used to control violent or self-injurious, behaviors such as biting or head-bumping. Methylphenidate (Ritalin) improves attention. Finally, parents and other family members require support, counseling and a chance to get away occasionally from their overwhelming duties.

How Prevalent?

About four of every 10,000 children, 75% of them boys, are diagnosed with autism. It’s believed, however, that many cases of mild to moderate autism go undetected.
(Source: “Autism Part I,” Harvard Mental Health Letter, March, 1997)

OTHER DISORDERS: In the Autistic Spectrum, autism is one of a number of developmental disorders believed to be caused by abnormalities in brain structure and function. Other disorders in the autistic spectrum include: Rett’s disorder, occurring only in girls, involves symptom of autism and mental retardation coupled with poor coordination and deficient growth. This disorder is characterized by a period of normal development, followed by a significant regression at about five months of age.

Asperger’s syndrome, involves deficits in two of the three usual autistic symptoms social interaction and limited interests. Verbal intelligence, however, is normal or superior. Like autistic individuals, persons with Asperger’s syndrome are prone to compulsive, repetitive behavior and speech. Since they don’t understand social subtleties, they often put others off by their abrupt and awkward approaches. Childhood disintegrative disorder, appears later than the other syndromes typically between ages 2 and 10. At this time a child suddenly loses previously gained skills involving language, social interaction, bowel or bladder control, motor skills and play.
(Source: American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), 1994)

Intensive Behavior Therapy: Does It Work?

One behavioral therapy program advocated for autistic children requires intensive effort from parents and a multidisciplinary treatment team. The seven-day-a-week program, starting at an early age involves a daycare staff, an occupational therapist, a speech therapist and a psychiatric consultant, all with specialized training, working closely with the parents to alter the home environment and change normal ways of reinforcing behavior. In one study of this method, 19 autistic children registered impressive gains compared to control group. Nine of the 19 children completed first grade in a regular classroom; by age 13 the average IQ of the study group was 83 compared to 50 at the start of the study. Children in the control group showed virtually no change. The method is difficult, time-consuming and expensive. Moreover, further studies are needed to confirm its effectiveness.
(Source: “Autism Part II,” Harvard Mental Health Letter, April, 1997)

Fluvoxamine Effective In Reducing Symptoms

The serotonin uptake inhibitor fluvoxamine maleate (Luvox, Solvay) has been tested and found effective in reducing some of the troubling symptoms of autistic disorder. In one 12-week study of 30 adults who had suffered from autism since early childhood, 53% of subjects taking the drug (compared to none of those taking placebo) showed significant improvement in language and reduction of aggressive actions and repetitive thoughts and behaviors. Few negative side effects were reported.
(Source: Grace Brooke Huffman, “Fluvoxamine for the Treatment of Autistic Disorders in Adults,” American Family Physician, March, 1997; Naomi Pfeiffer, “Old Drug Provides New Hope for Mental Illnesses,” Drug Topics, January 6, 1997)

Season of Birth a factor?

Danish researchers, confirming the findings of three other studies, found that autistic children were more likely to be born in spring and summer, particularly in March, rather than fall and winter. Looking up the birthdays of 328 autistic children born between 1945 and 1980, the researchers found a large number of birthdays in March and other spring and summer were more vulnerable to viral infections or nutritional deficiencies midway through their pregnancies that might have contributed to brain defects.
(Source: “Does Season of Birth Play a Role in Autism?” The Brown University Child and Adolescent Behavior Letter, April, 1996)

Viral Source?

Some researchers have theorized that some cases of autism might be linked to an immune system response to an environmental challenge such as the measles or herpes viruses. Support for this theory was found in a recent study at the University of Michigan. Researchers concluded that autistic persons who had been exposed at sometime to measles virus and herpes virus-6 had abnormally high levels of antibodies to brain proteins. Normal subjects also had antibodies to measles and herpes but no brain antibodies. The authors suggested that exposure to a virus may have triggered an autoimmune response in some children that interfered with the normal development of some brain tissues.
(Source: University of Michigan’s College of Pharmacy/Medscape Wire, October 30, 1998)

Referrences

“Autism Parts I and II,” Harvard Mental Health Letter, April 1997

Sharon Begley and Karen Springen, “Life in a Parallel World: A Bold New Approach to the Mystery of Autism,” Newsweek, May 13, 1996.

“Characteristics and Symptoms in Patients with Autism” American Family Physician, February 15, 1998

“Medication Improves Autism Symptoms, Studies Show,” American Medical News, November 18, 1996.

Isabelle Rapin, M.D., “Current Concepts: Autism,” NEJM, July 10, 1997

Fion J Scott and Simon Baron-Cohen, “Imagining Real and Unreal Things: Evidence of Dissociation in Autism,” Journal of Cognitive Neuroscience,” July, 1996.

Lorna Wing, “The Autistic Spectrum (Review article),” The Lancet, December 13, 1997.

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