Autism spectrum disorder

Overview

Autism spectrum disorder is a condition related to brain development that impacts how a person perceives and socializes with others, causing problems in social interaction and communication. The disorder also includes limited and repetitive patterns of behavior. The term "spectrum" in autism spectrum disorder refers to the wide range of symptoms and severity.

Autism spectrum disorder includes conditions that were previously considered separate — autism, Asperger's syndrome, childhood disintegrative disorder and an unspecified form of pervasive developmental disorder. Some people still use the term "Asperger's syndrome," which is generally thought to be at the mild end of autism spectrum disorder.

Autism spectrum disorder begins in early childhood and eventually causes problems functioning in society — socially, in school and at work, for example. Often children show symptoms of autism within the first year. A small number of children appear to develop normally in the first year, and then go through a period of regression between 18 and 24 months of age when they develop autism symptoms.

While there is no cure for autism spectrum disorder, intensive, early treatment can make a big difference in the lives of many children.

Signs and Symptoms 

People with ASD have difficulty with social communication and interaction, restricted interests, and repetitive behaviors. The list below gives some examples of common types of behaviors in people diagnosed with ASD. Not all people with ASD will have all behaviors, but most will have several of the behaviors listed below.

Social communication / interaction behaviors may include:

• Making little or inconsistent eye contact
• Appearing not to look at or listen to people who are talking
• Infrequently sharing interest, emotion, or enjoyment of objects or activities (including by infrequently pointing at or showing things to others)
• Not responding or being slow to respond to one’s name or to other verbal bids for attention
• Having difficulties with the back and forth of conversation
• Often talking at length about a favorite subject without noticing that others are not interested or without giving others a chance to respond
• Displaying facial expressions, movements, and gestures that do not match what is being said
• Having an unusual tone of voice that may sound sing-song or flat and robot-like
• Having trouble understanding another person’s point of view or being unable to predict or understand other people’s actions
• Difficulties adjusting behaviors to social situations
• Difficulties sharing in imaginative play or in making friends

Restrictive / repetitive behaviors may include:

• Repeating certain behaviors or having unusual behaviors, such as repeating words or phrases (a behavior called echolalia)
• Having a lasting intense interest in specific topics, such as numbers, details, or facts
• Showing overly focused interests, such as with moving objects or parts of objects
• Becoming upset by slight changes in a routine and having difficulty with transitions
• Being more sensitive or less sensitive than other people to sensory input, such as light, sound, clothing, or temperature
• People with ASD may also experience sleep problems and irritability.
• People on the autism spectrum also may have many strengths, including:
• Being able to learn things in detail and remember information for long periods of time
• Being strong visual and auditory learners
• Excelling in math, science, music, or art

Causes

Available scientific evidence suggests that there are probably many factors that make a child more likely to have autism, including environmental and genetic factors.

Available epidemiological data conclude that there is no evidence of a causal association between measles, mumps and rubella vaccine, and autism. Previous studies suggesting a causal link were found to be filled with methodological flaws(2)(3).

There is also no evidence to suggest that any other childhood vaccine may increase the risk of autism. Evidence reviews of the potential association between the preservative thiomersal and aluminum adjuvants contained in inactivated vaccines and the risk of autism strongly concluded that vaccines do not increase the risk of autism.

Assessment and care

A broad range of interventions, from early childhood and across the life span, can optimize the development, health, well-being and quality of life of autistic people. Timely access to early evidence-based psychosocial interventions can improve the ability of autistic children to communicate effectively and interact socially. The monitoring of child development as part of routine maternal and child health care is recommended.

It is important that, once autism has been diagnosed, children, adolescents and adults with autism and their carers are offered relevant information, services, referrals, and practical support, in accordance with their individual and evolving needs and preferences.

The health-care needs of people with autism are complex and require a range of integrated services, that include health promotion, care and rehabilitation. Collaboration between the health sector and other sectors, particularly education, employment and social care, is important.

Interventions for people with autism and other developmental disabilities need to be designed and delivered with the participation of people living with these conditions. Care needs to be accompanied by actions at community and societal levels for greater accessibility, inclusivity and support.

Human rights

All people, including people with autism, have the right to the enjoyment of the highest attainable standard of physical and mental health.

And yet, autistic people are often subject to stigma and discrimination, including unjust deprivation of health care, education and opportunities to engage and participate in their communities.

People with autism have the same health problems as the general population. However, they may, in addition, have specific health-care needs related to autism or other co-occurring conditions. They may be more vulnerable to developing chronic noncommunicable conditions because of behavioural risk factors such as physical inactivity and poor dietary preferences, and are at greater risk of violence, injury and abuse.

People with autism require accessible health services for general health-care needs like the rest of the population, including promotive and preventive services and treatment of acute and chronic illness. Nevertheless, autistic people have higher rates of unmet health-care needs compared with the general population. They are also more vulnerable during humanitarian emergencies. A common barrier is created by health-care providers’ inadequate knowledge and understanding of autism.

WHO resolution on autism spectrum disorders 

In May 2014, the Sixty-seventh World Health Assembly adopted a resolution entitled Comprehensive and coordinated efforts for the management of autism spectrum disorders, which was supported by more than 60 countries.

The resolution urges WHO to collaborate with Member States and partner agencies to strengthen national capacities to address ASD and other developmental disabilities.

WHO response

WHO and partners recognize the need to strengthen countries' abilities to promote the optimal health and well-being of all people with autism.

WHO's efforts focus on:

• increasing the commitment of governments to taking action to improve the quality of life of people with autism;
• providing guidance on policies and action plans that address autism within the broader framework of health, mental and brain health and disabilities;
• contributing to strengthening the ability of the health workforce to provide appropriate and effective care and promote optimal standards of health and well-being for people with autism; and
• promoting inclusive and enabling environments for people with autism and other developmental disabilities and providing support to their caregivers.

Diagnosis

Early signs of this disorder can be noticed by parents/caregivers or pediatricians before a child reaches one year of age. However, symptoms typically become more consistently visible by the time a child is 2 or 3 years old. In some cases, the functional impairment related to autism may be mild and not apparent until the child starts school, after which their deficits may be pronounced when amongst their peers.

Social communication deficits may include(1):

• Decreased sharing of interests with others
• Difficulty appreciating their own & others’ emotions
• Aversion to maintaining eye contact
• Lack of proficiency with use of non-verbal gestures
• Stilted or scripted speech
• Interpreting abstract ideas literally
• Difficulty making friends or keeping them

Restricted interests and repetitive behaviors may include(1):

• Inflexibility of behavior, extreme difficulty coping with change
• Being overly focused on niche subjects to the exclusion of others
• Expecting others to be equally interested in those subjects
• Difficulty tolerating changes in routine and new experiences
• Sensory hypersensitivity, e.g., aversion to loud noises
• Stereotypical movements such as hand flapping, rocking, spinning
• Arranging things, often toys, in a very particular manner

Parent/caregiver/teacher concerns about the child’s behavior should lead to a specialized evaluation by a developmental pediatrician, pediatric psychologist, child neurologist and/or a child & adolescent psychiatrist. This evaluation involves interviewing the parent/caregiver, observing, and interacting with the child in a structured manner, and sometimes conducting additional tests to rule out other disorders. In some ambiguous cases, the diagnosis of autism may be deferred, but otherwise an early diagnosis can greatly improve a child’s functioning by providing the family early access to supportive resources in the community.

The first step is seeking an evaluation. Most parents start with their pediatrician who is checking on developmental milestones. If your child is under the age of 3 years, you can obtain an evaluation through your local early intervention system. (Learn more about early intervention and find local contact information.)  If your child is over the age of 3, you can get an evaluation through your local school (even if your child does not go there).  Contact your local school’s preschool special education team to request an evaluation

Treatment 

Current treatments for autism spectrum disorder (ASD) seek to reduce symptoms that interfere with daily functioning and quality of life.1 ASD affects each person differently, meaning that people with ASD have unique strengths and challenges and different treatment needs.1 Therefore, treatment plans usually involve multiple professionals and are catered toward the individual.

Treatments can be given in education, health, community, or home settings, or a combination of settings. It is important that providers communicate with each other and the person with ASD and their family to ensure that treatment goals and progress are meeting expectations.

As individuals with ASD exit from high school and grow into adulthood, additional services can help improve health and daily functioning, and facilitate social and community engagement. For some, supports to continue education, complete job training, find employment, and secure housing and transportation may be needed.

Types of Treatments

There are many types of treatments available. These treatments generally can be broken down into the following categories, although some treatments involve more than one approach:

• Behavioral
• Developmental
• Educational
• Social-Relational
• Pharmacological
• Psychological
• Complementary and Alternative

Behavioral Approaches

Behavioral approaches focus on changing behaviors by understanding what happens before and after the behavior. Behavioral approaches have the most evidence for treating symptoms of ASD. They have become widely accepted among educators and healthcare professionals and are used in many schools and treatment clinics. A notable behavioral treatment for people with ASD is called Applied Behavior Analysis (ABA). ABA encourages desired behaviors and discourages undesired behaviors to improve a variety of skills. Progress is tracked and measured.

Two ABA teaching styles are Discrete Trial Training (DTT) and Pivotal Response Training (PRT).

DTT uses step-by-step instructions to teach a desired behavior or response. Lessons are broken down into their simplest parts, and desired answers and behaviors are rewarded. Undesired answers and behaviors are ignored.

PRT takes place in a natural setting rather than clinic setting. The goal of PRT is to improve a few “pivotal skills” that will help the person learn many other skills. One example of a pivotal skill is to initiate communication with others.

Developmental Approaches

Developmental approaches focus on improving specific developmental skills, such as language skills or physical skills, or a broader range of interconnected developmental abilities. Developmental approaches are often combined with behavioral approaches.

The most common developmental therapy for people with ASD is Speech and Language Therapy. Speech and Language Therapy helps to improve the person’s understanding and use of speech and language. Some people with ASD communicate verbally. Others may communicate through the use of signs, gestures, pictures, or an electronic communication device.

Occupational Therapy teaches skills that help the person live as independently as possible. Skills may include dressing, eating, bathing, and relating to people. Occupational therapy can also include:

Sensory Integration Therapy to help improve responses to sensory input that may be restrictive or overwhelming.

Physical Therapy can help improve physical skills, such as fine movements of the fingers or larger movements of the trunk and body.

The Early Start Denver Model (ESDM) is a broad developmental approach based on the principles of Applied Behavior Analysis. It is used with children 12-48 months of age. Parents and therapists use play, social exchanges, and shared attention in natural settings to improve language, social, and learning skills.

Educational Approaches

Educational treatments are given in a classroom setting. One type of educational approach is the Treatment and Education of Autistic and Related Communication-Handicapped Children (TEACCH) approach. TEACCH is based on the idea that people with autism thrive on consistency and visual learning. It provides teachers with ways to adjust the classroom structure and improve academic and other outcomes. For example, daily routines can be written or drawn and placed in clear sight. Boundaries can be set around learning stations. Verbal instructions can be complimented with visual instructions or physical demonstrations.

Social-Relational Approaches

Social-relational treatments focus on improving social skills and building emotional bonds. Some social-relational approaches involve parents or peer mentors.

The Developmental, Individual Differences, Relationship-Based model (also called “Floor time”) encourages parents and therapists to follow the interests of the individual to expand opportunities for communication.

The Relationship Development Intervention (RDI) model involves activities that increase motivation, interest, and abilities to participate in shared social interactions.

Social Stories provide simple descriptions of what to expect in a social situation.

Social Skills Groups provide opportunities for people with ASD to practice social skills in a structured environment.

Pharmacological Approaches

There are no medications that treat the core symptoms of ASD. Some medications treat co-occurring symptoms that can help people with ASD function better. For example, medication might help manage high energy levels, inability to focus, or self-harming behavior, such as head banging or hand biting. Medication can also help manage co-occurring psychological conditions, such as anxiety or depression, in addition to medical conditions such as seizures, sleep problems, or stomach or other gastrointestinal problems.

It is important to work with a doctor who has experience in treating people with ASD when considering the use of medication. This applies to both prescription medication and over-the-counter medication. Individuals, families, and doctors must work together to monitor progress and reactions to be sure that negative side effects of the medication do not outweigh the benefits.

Psychological Approaches

Psychological approaches can help people with ASD cope with anxiety, depression, and other mental health issues. Cognitive-Behavior Therapy (CBT) is one psychological approach that focuses on learning the connections between thoughts, feelings, and behaviors. During CBT, a therapist and the individual work together to identify goals and then change how the person thinks about a situation to change how they react to the situation.

Complementary and Alternative Treatments

Some individuals and parents use treatments that do not fit into any of the other categories. These treatments are known as Complementary and Alternative treatments. Complementary and alternative treatments are often used to supplement more traditional approaches. They might include special diets, herbal supplements, chiropractic care, animal therapy, arts therapy, mindfulness, or relaxation therapies. Individuals and families should always talk to their doctor before starting a complementary and alternative treatment.

There may be other treatments available for individuals with ASD. Talk to a doctor or healthcare provider to learn more.