Autism behavior and treatement

History

Behavioral and developmental features that suggest autism include the following:

• Developmental regression
• Absence of protodeclarative pointing
• Abnormal reactions to environmental stimuli
• Abnormal social interactions
• Absence of symbolic play
• Repetitive and stereotyped behavior

Developmental regression

Between 13% and 48% of people with autism have apparently normal development until age 15-30 months, when they lose verbal and nonverbal communication skills. These individuals may have an innate vulnerability to develop autism. Although regression may be precipitated by an environmental event (eg, immune or toxic exposures), more likely it is coincidental with other environmental events.

Protodeclarative pointing

Protodeclarative pointing is the use of the index finger to indicate an item of interest to another person. Toddlers typically learn to use protodeclarative pointing to communicate their concern for an object to others. The absence of this behavior is predictive of a later diagnosis of autism.^{[89, 90]}

The presence of protodeclarative pointing can be assessed by interview of the parent or caregiver. Screening questions include "Does your child ever use his or her index finger to point, to indicate interest in something?" A negative response to this question suggests the need for a specialized assessment for possible pervasive developmental disorder.

Environmental stimuli

In contrast to toddlers with delayed or normal development, toddlers with autism spectrum disorder are much more interested in geometric patterns. Toddlers who prefer dynamic geometric patterns to participating in physical activities such as dance merit referral for evaluation for possible autism spectrum disorder.^[91]

Parents of children with autism report unusual responses to environmental stimuli, including excessive reaction or an unexpected lack of reaction to sensory input. Certain sounds (eg, vacuum cleaners or motorcycles) may elicit incessant screaming. Playing a radio, stereo, or television at a loud level may appear to produce hyperacusis, a condition in which ordinary sounds produce excessive auditory stimulation of a painful magnitude. Sometimes parents must rearrange the family routine so that the child is absent during noisy housekeeping activities.

Children with autistic disorder may also display exaggerated responses or rage to everyday sensory stimuli, such as bright lights or touching.

Social interactions

Individuals with autism may display a lack of appropriate interaction with family members.^[92] Moreover, difficulties in social interactions are common. Children may have problems making friends and understanding the social intentions of other children and may instead show attachments to objects not normally considered child oriented. Although children with autistic disorder may want to have friendships with other children, their actions may actually drive away these potential companions. They may also exhibit inappropriate friendliness and lack of awareness of personal space.

Isolation likely increases in adolescence and young adulthood. Interviews with a representative sample of 725 youths with autism (mean age 19.2 y) determined that the majority had not in the preceding year gotten together with friends or even spoken with a friend on the telephone.^[93]

High pain threshold

An absence of typical responses to pain and physical injury may also be noted. Rather than crying and running to a parent when cut or bruised, the child may display no change in behavior. Sometimes, parents do not realize that a child with autistic disorder is hurt until they observe the lesion. Parents often report that they need to ask the child if something is wrong when the child's mood changes, and may need to examine the child's body to detect injury.

Language

Speech abnormalities are common. They take the form of language delays and deviations. Pronominal reversals are common, including saying "you" instead of "I." Some speech habits, such as repeating words and sentences after someone else says them, using language only the child understands, or saying things whose meaning is not clear, may occur not only in autism but in other disorders as well.

Play

Baron-Cohen and colleagues demonstrated that the absence of symbolic play in infants and toddlers is highly predictive of a later diagnosis of autism.^{[89, 90]}Therefore, screening for the presence of symbolic play is a key component of the routine assessment of well babies. The absence of normal pretend play indicates the need for referral for specialized developmental assessment for autism and other developmental disabilities.

Odd play may take the form of interest in parts of objects instead of functional uses of the whole object. For example, a child with autistic disorder may enjoy repeatedly spinning a wheel of a car instead of moving the entire car on the ground in a functional manner. The nonfunctional play of a boy with autism is illustrated in the video files below. Please note that videos represent a diagnostic assessment of a child. The child is allowed to exhibit the abnormal behaviors to demonstrate those items on a video for confirmation by blind raters. If the child exhibited behaviors danger to himself, such as self-injurious behaviors, or dangerous to other, such as attacking others, then the examiner would intervene to prevent injury to the child and others. The videos do not in any way represent treatment for the disorder. (The second and third videos also demonstrate an aforementioned trait, the lack of appropriate interaction with family members

Approach Considerations

Individual intensive interventions, including behavioral, educational, and psychological components, are the most effective treatments of autistic disorder. Beginning the treatment early in infancy increases the likelihood of a favorable outcome. Thus, regular screening of infants and toddlers for symptoms and signs of autistic disorder is crucial because it allows for early identification of these patients.

Individuals with autism spectrum disorder and unspecified pervasive developmental disorder typically benefit from behaviorally oriented therapeutic programs developed specifically for this population. Autistic children should be placed in these specialized programs as soon as the diagnosis is entertained.

Parents, teachers, pediatricians, and other health care providers are advised to seek the assistance of people who are familiar with early intervention programs for children with autistic disorder. The Autism Society can help parents to obtain appropriate referrals for optimal interventions.

Parents understandably become exhausted by the relentless performance of challenging behaviors by their child with autism. A specially trained educator or behavioral psychologist can help to teach them effective ways to modify these challenging behaviors. Parents also frequently benefit from temporary respite from the child.

The possible benefits from pharmacotherapy must be balanced against the likely adverse effects on a case-by-case basis. In particular, venlafaxine may increase high-intensity aggression in some adolescents with autism.^[8]

Limited, largely anecdotal evidence suggests that dietary measures may be helpful in some children with autism. Avoidance of certain foods, notably those containing gluten or casein, and supplementation with specific vitamins and minerals have reportedly proved helpful in select cases.

The National Autism Center has initiated the National Standards Project, which has the goal of establishing a set of evidence-based standards for educational and behavioral interventions for children with autism spectrum disorders. The project has identified established, emerging, and unestablished treatments.