Some of your questions answered.
Autism is a developmental disorder that is diagnosed when a child demonstrates problems or abnormalities in language, socialization, and behavior. For example, autistic children typically have significant speech delays; they may be nonverbal or only babble, exhibit a limited vocabulary, or use words or phrases in a highly repetitive and obsessive fashion, e.g. use the same word or phrase over and over again. Socialization is also a problem with autistic children often either being quite withdrawn and “off in their own world” or they may approach others in an attempt to socialize but, once involved in the social encounter, may not be sure of what to do or say, which contributes to social withdrawal. Thirdly, there are unusual mannerisms, sometimes referred to as “self-stimulatory behaviors” that may include toe-walking (that continues past 18 months of age), hand-flapping, staring for extended periods of time, jumping, obsessively clinging to a particular toy, among many other unusual behaviors. These odd behaviors are referred to as “self-stimulatory” because it seems that the child is “stimulated” by the behavior and finds the activity to be reinforcing. However, at the same time, these behaviors tend to interfere with normal socialization. Not uncommonly, there are also hyper or hypo-sensitivities (for example, being extra sensitive to particular fabrics, or insensitive to pain), sleep difficulties (not sleeping throughout the night), food-related issues (being exceptionally finicky or having difficulties with portion management, i.e. putting too much food in their mouth at one time), and difficulties tolerating changes in routine.
Asperger’s Disorder was coined by Hans Asperger in 1944. He described individuals who present with a similar pattern of unusual behavior including, for example, that these individuals are fully fluent and of average intelligence, but often use language in an odd and peculiar manner and display a mechanical quality to the flow of their speech. Individuals diagnosed with Asperger’s disorder also tend to be rather obsessive about various topics of interest and will speak on these topics, and sometimes nothing else, for days or weeks before moving on to some other topic. However, the hallmark and most predominate feature is poor socialization skills. These individuals tend to have poor eye contact, disturbed personal boundaries (can be too intrusive in how close they stand to someone), interrupt, not understand how to begin and end a conversation, and have difficulty with changes in routine. However, individuals with Asperger’s Disorder do not experience difficulty with speech fluency and are generally lacking in those “self-stimulatory” behaviors, compared to a child with autism who has difficulty with both of these areas.
The behaviors and delays described above begin to surface before the second or third birthday, and sometimes before the first birthday. There are times when the child may develop “normally” for the first 18 months or so, then regress in the form of losing words, socially withdrawing, and displaying those aforementioned odd behaviors.
There is no known cause of autism. Numerous theories and suspicions abound, but no one knows for sure. Some have implicated vaccines, but the subsequent research has been inconsistent with some findings providing support that vaccines are the culprit but most research findings suggesting otherwise. Genetics seem to play a role given that, for example, the condition is more prevalent in first degree relatives than otherwise. Researchers are also analyzing brain structure, chromosomal abnormalities, and various medical conditions.
No, autistic children are quite different from one another, just as all children are unique. Moreover, children with autism can present quite differently in the severity and extent of symptoms. For that reason, Autistic Disorder is often referred to as a “spectrum” disorder. This means that the signs and symptoms are on a “spectrum” or “continuum” from one extreme to the other. For example, one particular “autistic” child may be able to speak in short phrases, demonstrate affection with his parents, and only occasionally hand-flap. However, another child, also diagnosed with autism, may be completely nonverbal, exhibit no affection, and display incessant odd behaviors including toe-walking, spinning objects, and obsessively lining-up objects. The “spectrum” can also refer to the wider scope of diagnoses including Autism, Pervasive Developmental Disorder Not Otherwise Specified (PDDNOS), and Asperger’s Disorder. The two extremes on this spectrum consist of Autistic Disorder at one end of the spectrum, being quite debilitating, with Asperger’s Disorder at the other end. Asperger’s Disorder will be described further below and it consists of a number of autistic-like signs including severe socialization deficits, a tendency to obsess on topics, and an odd use of language. However, people with Asperger’s disorder verbally communicate without too much problem and typically want to be social, they just aren’t sure how.
Many children display only some of the necessary signs for Autism or Asperger’s Disorder, and therefore do not meet full diagnostic criteria for either. In those instances, the child may fall into a broader diagnostic category called “Pervasive Developmental Disorder Not Otherwise Specified,” which is also known as “PDDNOS.” or just plain “PDD.”
Usually, signs begin to surface early-on, between one and three years of age. Typically, a parent or pediatrician expresses concerns about the child’s lack of language development and related abnormalities. The pediatrician may then refer the parents to a facility that specializes in the evaluation and treatment of autism spectrum disorders, such as Community Psychiatric Centers (C.P.C.), for a comprehensive evaluation. At C.P.C., the child is evaluated by either Dr. Lowenstein, M.D. who is a Board Certified Child Psychiatrist, or Dr. Carosso, Psy.D. who is a Licensed Psychologist and Certified School Psychologist. Between them, they have over forty-five years of experience assessing and treating developmentally delayed children. The evaluation includes a complete history and assessment of current functioning including of the child’s social engagement, play skills, speech and language capacity, eye contact, assessment of any “self-stimulatory behaviors, among many other targeted areas. The assessment at C.P.C. will culminate in the explanation of the diagnosis, treatment considerations, ample time to answer questions, and a comprehensive written report with abundant recommendations and resources.
Yes, it is not uncommon for psychiatric conditions to co-occur. For example, a child with autism may also display over activity, inattention, heightened impulsivity and/or oppositionalism. Consequently, a comprehensive treatment plan is necessary to target not only developmental delay and abnormalities, but also these behavioral issues. Depression can also be observed, particularly in children with Asperger’s Disorder given the tendency to experience rejection by peers. As will be described further below, counseling and, at times, medication management can be quite beneficial.
After a comprehensive assessment is completed and an accurate diagnosis is provided and explained, it is time to focus on treatment. There are a number of options for a child within the autistic spectrum but most treatment strategies are based in “Applied Behavioral Analysis,” which is the process of analyzing the small steps needed to complete any given task as well as potential reinforcers (those things that help to increase the chance that the preferred behavior will occur) among a myriad of other considerations. The subsequent information is used to develop “discrete trial programs” to help the child learn the individual steps toward task completion, such as identifying the name of an object to work toward the goal of asking for the object. In that manner, first the child learns, through repeated trials, the sub-steps for completing each activity leading-up to learning the entire task. This strategy is also applied to teaching language in a strategy referred to as “Verbal Behavior” that was coined by B.F. Skinner in 1938 in his classic book “The Behavior of Organisms.” Other treatments include Relationship Development Therapy, the TEACCH program, and Greenspan methods, all of which use various strategies and floor-play to facilitate social skill development. These treatment strategies are generally supported by research results, particularly discrete trial regimens. There are also various food and supplement-related interventions including, for example, eliminating gluten and casein (diary and wheat products) from the diet, with some parents reporting subsequent positive results but, overall, the research results being inconclusive. Various social-skill development programs are used for children with Asperger’s Disorder. Self-stimulatory behavior is redirected into more appropriate behavior such as, for example, directing a child who rocks to use a rocking chair. Sleep and food-related difficulties are also targeted with behavioral approaches and, if necessary, referral for a psychiatric consult and/or to a local feeding clinic. In that regard, clinicians at C.P.C. use a wide variety of treatment options that are tailored to take advantage of the child’s strengths while targeting weaknesses. C.P.C. clinicians are not limited to any one approach but are well-versed in most or all treatment modalities to meet the needs of any child diagnosed with autism.
No medication has been found to cure Autism/PDD. However, studies have shown that various medications may help children to profit from educational and other behavioral interventions, and can help reduce some of the target behaviors associated with Autism/PDD. Medications can also treat the so called “co-morbid” conditions often found in children with autism such as ADHD, Tourette’s Disorder, Depression, and OCD.
Major tranquilizers or ‘neuroleptics’ such as Haldol, Risperdal, Zyprexa, Seroquel, and Abilify have been found to reduce levels of withdrawal, stereotypic movements, aggressiveness and self-abuse. Stimulant medications such as Adderall, Concerta, Metadate, Ritalin, Focalin, and Methylin have been found to reduce levels of over activity, poor concentration, distractibility, and impulsiveness. Tic-like and obsessive-compulsive behaviors, as well as some forms of self-injury, have been successfully treated with medications such as Tenex, Clonidine, Prozac, Luvox, and Anafranil. Antidepressants and mood stabilizers like Lithium and Depakote have been reported to reduce some signs of depression and mood instability. Beta-blocker type medications, such as Inderal, usually indicated in the treatment of hypertension, have been found to reduce aggression.
Evaluations of children for Autism/PDD should include a medical history and physical examination, neurological testing, as well as vision and hearing testing to rule out the presence of inherited disorders such as Fragile X syndrome or tuberous sclerosis, hearing loss, and seizure disorders, associated with Autism. A DNA test for Fragile X syndrome is available, as are other genetic screening and chromosomal analytic tests to rule out inherited metabolic disorders.
Wraparound services, offered through C.P.C., is a state-funded service through Medical Assistance that provides the opportunity for children diagnosed with autism to procure intensive services, for hours per week if necessary, to treat the disorder in the most comprehensive and intensive manner possible. Staff includes a Behavioral Specialist Consultant (BSC) who has at least a Masters Degree and specialized training in treating children with developmental disorders. Also on the team is a Bachelor’s level Therapeutic Staff Support (TSS) worker who also has specialized training and carries out the day-to-day programming necessary to help the autistic child learn adaptive skills. A Mobile Therapist (MT) may also be used to provide counseling. This service can be remarkably effective. Parents can obtain Medical Assistance for their child, regardless of income, through what is known as the “loophole.” Please contact C.P.C. toll free at 1-877-899-6500 for more information about wraparound services and obtaining Medical Assistance.
Outcome is difficult to predict. Many children demonstrate remarkable progress such that, for example, in only a few years, the a child may be barely distinguishable from his or her peers. However, other children continue to demonstrate significant symptoms. Nevertheless, virtually all children provided intensive treatment display progress that may manifest, for example, in improved eye contact, being able to carry-on a conversation for two exchanges rather than only one, or being able to express four-word, as opposed to two-word expressions. Improvements may seem small but in terms of being able to function at a higher level in school and in the community, and ongoing improvements over time, these small changes can add up to substantial advances. Consequently, the need for intensive and long-term treatment is vital.