Autism
Autism is a disorder in which a young child cannot develop normal social relationships, uses language abnormally or not at all, behaves in compulsive and ritualistic ways, and may fail to develop normal intelligence.
Autism, the most common of the pervasive developmental disorders (see Section 23, Chapter 286), occurs in 5 of 10,000 children. Symptoms of autism may appear in the first 2 years of life and always before age 3. The disorder is 2 to 4 times more common in boys than in girls. Autism is different from mental retardation, although many children with autism have both.
The specific cause of autism is not fully understood, although it is clearly a biologically determined disorder. Several chromosomal abnormalities, such as fragile X syndrome, contribute to the development of autism. Prenatal infections, for example, viral infections such as rubella or cytomegalovirus, may also play a role. It is clear, however, that autism is not caused by poor parenting, adverse childhood conditions, or vaccination.
Symptoms
Autistic children develop symptoms in at least 3 of the following areas: social relationships, language, behavior, and sometimes intelligence. Symptoms range from mild to severe and often keep children from functioning independently in school or society. In addition, about 20 to 40% of autistic children, particularly those with an intelligence quotient (IQ) less than 50, develop seizures before reaching adolescence.
Social Relationships: An autistic infant does not cuddle and avoids eye contact. Although some autistic infants become upset when separated from their parents, they may not turn to parents for security as do other children. Older autistic children often prefer to play by themselves and do not form close personal relationships, particularly outside of the family. When interacting with other children, they do not use eye contact and facial expressions to establish social contact, and they are not able to interpret the moods and expressions of others.
Language: About 50% of autistic children never learn to speak. Those who learn do so much later than normal and use words in an unusual way. They often repeat words spoken to them (echolalia) or reverse the normal use of pronouns, particularly using you instead of I or me when referring to themselves. These children rarely have an interactive dialogue with others. Autistic children often speak with an unusual rhythm and pitch.
Behavior: Autistic children are very resistant to changes, such as new food, toys, furniture arrangement, and clothing. They often become excessively attached to particular inanimate objects. They often repeat certain acts, such as rocking, hand flapping, or spinning objects in a repetitive manner. Some may injure themselves through repetitive behaviors such as head banging or biting themselves.
Intelligence: About 70% of children with autism have some degree of mental retardation (an IQ less than 70). Their performance is uneven; they usually do better on tests of motor and spatial skills than on verbal tests. Some autistic children have idiosyncratic or "splinter" skills, such as the ability to perform complex mental arithmetic or advanced musical skills. Unfortunately, such children are often not able to use these skills in a productive or socially interactive way.
Diagnosis
The diagnosis is made by close observation of the child in a playroom setting and careful questioning of parents and teachers. Standardized tests, such as the Childhood Autism Rating Scale, may help the evaluation. In addition to giving standardized tests, a doctor should perform certain tests to look for underlying treatable or inherited medical disorders (such as hereditary disorders of metabolism (see Section 23, Chapter 282) and fragile X syndrome (see Section 23, Chapter 266)).
Prognosis and Treatment
The symptoms of autism generally persist throughout life. The prognosis is strongly influenced by how much usable language the child has acquired by age 7. Autistic children with below-normal intelligence--for example, those who score below 50 on standard IQ tests--are likely to need full-time institutional care as adults.
Autistic children may benefit from certain intensive behavioral modification techniques. Children whose IQs are normal may be helped by psychotherapy aimed at correcting social difficulties. Special education is crucial and often includes speech, occupational, physical, and behavioral therapy within a program equipped to manage children with autism.
Drug therapy cannot change the underlying disorder. However, the selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, paroxetine, and fluvoxamine, are often effective in reducing ritualistic behaviors of autistic children. Antipsychotic drugs, such as risperidone, may be used to reduce self-injurious behavior, although the risk of side effects (such as movement disorders) must be considered.
Although some parents try special diets, gastrointestinal therapies, or immunologic therapies, currently there is no good evidence that any of these therapies helps children with autism.
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