Autistic Disorder

Autistic disorder is characterized by devastating impairments in a young child’s communication and language skills, disinterest in social interaction, and preference for repetitive, stereotyped behaviors. Although it is usually present in infancy, no physical indicators or hard neurological signs facilitate an accurate neurological diagnosis before the age of three. Early signs of autism include lack of eye contact, failure to cuddle with affection, and nonreciprocal smiling patterns. Children may not speak or may be unable to carry on a meaningful conversation, other than making requests to get their own needs fulfilled. Autistic children may engage in idiosyncratic verbalizations, especially echolalia or the repeating of recently heard or preferred idiosyncratic phrases without prosody or communicative intent. When left to themselves, autistic children frequently become absorbed into stereotyped actions, especially spinning objects, body rocking, and flapping their hands. They are repetitive specialists and can sustain attention on their preferred activities for hours but will actively resist changes in their routines or rituals.

Autistic disorder occurs at a rate of 2 to 5 cases per 10,000 individuals and is more likely to be present in males than in females at a ratio of 4 to 1. At this time there is no definitive test for autism. Amniocentesis has not yet identified any chromosomal or chemical predictor of autism. Diagnosis occurs on the basis of symptom profiles and elimination of competing diagnoses such as deafness or expressive language disorders. Neither is there full consensus in research and theory about the causes of autistic disorder.

Early infantile autism was first labeled by Kanner in 1943 from his clinical work with a sample of 11 children. The term autism had first been used by Eugen Bleuler in 1919 to describe the withdrawal from the outside world seen in adult schizophrenics. Early theory focused on whether autism should be viewed as a childhood version of schizophrenia. However, autism seems to follow a more uniform course than the pattern of remission and relapse in schizophrenia and is essentially marked by the absence of fantasy, play, and hallucinations, while schizophrenics complain of excessive and confusing internal images. In the psychoanalytic thought of Bettelheim, the disorder is caused by attachment trauma in infancy, the so-called refrigerator parents who cannot respond nurturantly to their children. However, research suggests that parents of autistic children are not significantly different from parents of any severely chronically ill child.

Although the causal mechanisms have not been isolated, it is believed that the disorder originates early in neonatal brain development. The developing brain sustains some damage, perhaps mediated by maternal illness, chemical toxins, viral agents, environmental pollutants, or genetic susceptibility that affects its continued growth. As a consequence the central nervous system substrata necessary for processing complex perceptual information, especially information critical for establishing social reciprocity, does not mature through infancy. Self-stimulation through kinesthetic actions seems to help the children regulate their arousal and soothe their perceptual processing disturbance so that they can feel calm.

Children do not outgrow autism or the concomitant mental retardation. Better prognosis is marked by the presence of language before the age of five, ability to benefit from observational learning (imitation), absence of severe symptoms such as self-injury and aggression, and ability to demonstrate intelligence with an intelligence quotient above 50. Most autistic persons are unable to manage rudimentary skills of daily living and require substantial supervision and care through their adult years. Treatment is more effective if it occurs as early as possible with a focus on language, functional communication, and motivational assessment. Medication may be useful for management of behavioral outbursts and mood disturbances but does not resolve the core symptoms of autistic disorder. The innovative technique of facilitated communication teaches autistic persons to use keyboards as language tools and has been useful for some autistic people. Intervention typically consists of efforts to teach adaptive skills, manage disruptive behavior, and communicate for self-advocacy purposes so that persons with autistic disorder can care for themselves in as independent a way as possible.