Along with the DSM-V, Autism has a long history. Autism Spectrum Disorder is the name that was given to the classification of a range of levels of severity; although, this was not always the case. Let’s start from the beginning or rather the discovery of Autism, which will then slowly lead up to where we stand currently. The term ‘Autism’ was first used by a Swiss psychiatrist by the name of Eugene Bleuler. He primarily used it to categorize Schizophrenia, which of course is not the case today; Schizophrenia has no association with Autism in the modernized studies of the contemporary sciences of psychology. The expression comes from the Greek word ‘Autos’ which means ‘self’. Bleuler intended to describe Schizophrenics with this term in which he saw them as the isolated-self. He had started using this word to classify the people he diagnosed around 1911. However, this is only the origin of the label given to the disorder, but Autism itself dates back further than we know of.
The earliest documented case of Autism was found from court case files in 1747. This case featured Hugh Blair of Borgue who in the present day would be classified as having Autism. A book called “Autism in History: The Case of Hugh Blair of Borgue” by Rab Houston and Uta Frith was written to show that Autism is a timeworn illness; we have only discovered it later and labeled it, although it has existed before our discovery. The book talks about the Scotsman Hugh Blair who lived in the house of brogue; it mentions his behaviors of straying away from social interferences and other associated behaviors. The authors discuss how Hugh Blair has peculiar interests, such as attending funerals and visiting people in inappropriate timings and then wondering why they had not been kind and welcoming. This clearly related to not understanding certain social cues that people show at times, directly relating to a symptom of autism. The reason this was brought to historical attention was because of Hugh’s brother, who brought a case to the court that suggested that Hugh was not fit for marriage and that he should not stay married to his own wife. The court sided and agreed with Hugh’s brother; therefore, announcing their marriage annulled. Although, this did not matter because Hugh and his ex-wife continued to live happily together, having two children, before the death of Hugh Blair of Borgue in 1765.
There was a great deal of confusion during the period between Leo Kanner’s research and Bruno Bettelheim’s theories. Though, by this time they have established that Autism is a disorder which consists of an absence of the development of behavior in an individual. Leo Kanner contributed to the start of a new definition for Autism in 1943 through working with children with behavioral struggles. He described it as “early infantile autism,” from observing the similarities of behaviors and actions from the children he had been examining. While, Bruno Bettelheim believed that Autism was caused by the absence of love given to a child by a mother which he called “Refrigerator Mothers.” This theory was contradicted by a psychologist called Bernard Rimland, who published a book further developing the definition that Kanner initially began to explain. In addition, in 1944, a German scientist by the name of Hans Asperger noticed another sort of Autism which he titled “Asperger’s syndrome.” He recorded children that were quite intelligent, yet struggled with social interactions and specific obsessive interests.
Additional research on twins, helped uncover that Autism is in fact somehow related to or caused by genetics. Jumping a few years ahead, in 1980, “Infantile Autism” had been added into the DSM-III. Afterwards, this title was replaced by “Autistic Disorder” which came with certain developmental therapies which proved to be useful. Later on, in 1994, the Autism Spectrum Disorder was created and fitted in the DSM-IV, including the following subtypes of the spectrum: Autistic Disorder, Asperger’s Syndrome, Rett Syndrome, PDD-NOS, and Childhood Disintegrative Disorder. Finally, in 2013, the ASD was no longer classified by type, but rather by levels, in which there are three levels of ASD and the higher the level, the more severe the symptoms are.
Autism Spectrum Disorder
As a result of the history there were a lot of different meanings for the specified disorder now directed to as ASD. People with this developmental impairment are now all classified under a single spectrum. Different people are affected in different ways, leading to distinctive conditions, which means that they need to be sub classified, in order to effectively know how to treat them. So, in ASD there are three levels, otherwise called functioning levels, in which the severity of autism is categorized in. Those three levels go from mild to moderate to extremely severe. The level of severity is justified through the person’s ability of social communication, flexibility, sensory sensitivity, and his/her overall behavior. Now allow for a deeper explanation of all three levels:
Level 1
High-Functioning Autism or level one of the spectrum is most closely related to the previous classification called Asperger’s Syndrome. What this means is that the person can be independent, while still having some difficulties with their communication. People with this level of autism will have well-built verbal skills but appear to have a challenging time in a normal conversation or understanding of tone or voice of the other person. This phenomenon can be explained by the two areas of the brain by the names of Wernicke’s and Broca’s areas. The Wernicke’s area helps with the comprehension of speech and language, while the Broca’s area develops and produces speech. This is the reason for some being able to speak, although still not understanding certain parts of speech.
In addition, they will still carry some symptoms. Although, the symptoms are present they are milder and less engaging, such as repetitive behavior. They will still have disruptive behavior, it just appears in a gentler form.
Though, symptoms are still visible in High-Functioning Autism, some conditions are not applied. Individuals in this spectrum maintain a normal or even above-average IQ.
The mild form of autism in spectrum is still troubling for people, it is just on a lesser degree than the rest of the spectrum. Therefore, the individuals still have atypical social interactions, which means they struggle to interpret people’s body language or elements such as satire or sarcasm.
Level 2
Level two in the spectrum can offer a wider range of problems. People with this classification can be independent in certain circumstances, so they would be able to maintain some sort of job. Although, the person will be affected by behavioral problems such as tip toeing or spinning in circles. These behaviors would be repeated by the individual and can be intrusive with the people around them.
Another difficulty would be with their equipped communication skills. This time around they not only wouldn’t be able to pick up on sarcasm and such language devices, they will also have problems with their verbal skills (speech). Their speech would be consistent of simplified and repetitive words.
Their IQ’s would be in the group of a normal to below average intelligence. In this stage of autism people find particular tasks to be of greater difficulty than regularly. Their difficulties in behavior extend to their job, school, and social spaces.
Level 3
The third and most severe case of autism is called Low-Functioning Autism. In this criterion, both children and adults need substantial support from their caregivers. Individuals at this part of the spectrum cannot take care of themselves alone, they need support. In other words, they cannot be independent, although this is what we want to be enabled through more research for ASD. Support can be provided and in certain cases people can live independently.
As expected from the most severe level of autism, it has the most severe symptoms or conditions in every aspect. People with this diagnosis are subject to harsh deficits of communication skills. They are classified as non-verbal and have great difficulty communication with or through spoken words. They can also misinterpret verbal, as well as non-verbal cues.
Their cognition is impaired to an extent which it affects their everyday life of behavior and self-care. Their social skills are also diminished to a point where they might not be able to communicate with others and this leads to them not wanting to continue such actions of socializing. They prefer to be left alone and it is often very tough to catch their attention. Because of these severe conditions, their average IQ’s tend to fall below average.
At this stage of the spectrum there are some behaviors associated which you would not find in the rest of the spectrum, such as spinning, flapping hands, or rocking back and forth.
A research from the University of Wisconsin followed 241 individuals with ASD, ranging in age from 10 to 52 year olds, for nearly five years. The researchers used standardized tests to measure the symptoms and behaviors overtime, tracking and monitoring their improvement or deterioration. A researcher, Marsha Mailick Seltzer, PhD, says "For any individual symptom, and there are three dozen or so we looked at, there is always a very small group of people who got worse, a modest group in the middle who were stable, and a majority who showed improvement," "Generally speaking, people who are improving in one area are improving across the board." Therefore, it is not impossible for people’s symptoms to improve from one level of severity to another less severe one. [DeNoon, D. J. (2007, September 27). Autism Improves in Adulthood. Retrieved from https://www.webmd.com/brain/autism/news/20070927/autism-improves-in-adulthood#1]
Characteristics
Autism differs from person to person in severity and symptoms, which can differ from mild to severe and can change with time. The general characteristics of Autism fall into two categories: Social interaction and communication problems. For example, finding difficulties in conducting conversations, which limits sharing of interests or feelings, as well as challenges in comprehension or reacting to meaningful gestures such as eye connections and expressions, which leads to an insufficiency in creating, keeping, and understanding relationships. The second category is difficulty in relating to people, things or events, which is essentially difficulty in making friends and interacting with peers, as well as being unable to maintain eye contact among other signs of every day body language.
Despite this, both categories still possess some similarities such as restricted and repetitive patterns of behaviors, interests or activities. People with autism spectrum disorder may differ from each other in many aspects, but they all have limited and repetitive patterns of behavior that they consistently do, for example, repeating the same movements such as rocking back and forth over and over again, as well as being sensitive to certain sounds, like telephone noises or static.
Autism is generally characterized by clear marked difficulties in behavior, social interaction and communication. Some of these characteristics are common among sufferers of the illness, while others are typical of the disability but not necessarily exhibited by all patients.
Behavioral
People who suffer from autism may exhibit unusual behavior due to the unique difficulties they have responding to their environment. Their behavior is generally an attempt by them to communicate their feelings or to cope with a situation. Behavioral problems may occur as the result of their heightened sensitivity to a sound or something they may have seen or felt. Due to the suffering of autism they in turn react differently to it than other people might, leading to sporadic or odd behavior.
For people who have autism, strictly sticking to routines and spending their time in repetitive behaviors are ways for them to reduce uncertainty and maintain the predictability of their environment, in other words maintaining a sort of sameness throughout their daily activities. This leads to them doing a specific behavior repetitively as they feel safe and assured doing it, other than trying something new.
Other behaviors commonly seen in patients may include unusually intense or focused interests, stereotyped and repetitive body movements such as hand flapping or clapping, repetitive use of objects such as repeatedly switching lights on and off or lining up toys, insistence on sticking to routines such travelling the same route home each day and doing things in exactly the same order every time. Unusual sensory interests such as sniffing objects or staring intently at moving objects can also be an endeavor of this illness. Sensory sensitivities including avoidance of everyday sounds and textures such as hair dryers, vacuum cleaners and sand are characteristics followed by the diagnosed.
Social interaction
Sufferers of autism also have difficulty establishing and maintaining relationships as they do not respond to many of the non-verbal forms of communication that many of us take for granted like facial expressions, physical gestures and eye contact. They are often unable to understand and express their needs just as they are unable to interpret and understand the needs of others. This impairs their ability to share interests and activities with other people, and this leads to them commonly appearing distant and aloof.
Because they are often delayed in their speech and struggle to make sense of other non-verbal forms of communication, they may withdraw into repetitive play and behavior, which leads to avoidance of interaction, further reinforcing the flaw in their social interaction. This difficulty manifests in several ways, the most common being limited use and understanding of non-verbal communication such as eye contact, facial expression and gestures, difficulties forming and sustaining friendships, lack of seeking to share enjoyment, interests and activities with other people and difficulties with social and emotional responsiveness.
Communication
People with autism often have communication difficulties in one form or another, as there are some people with autism who speak fluently, others who are speech impaired to varying degrees and even some who are unable to speak at all. Of those who can speak, they will often use language in a very limited or unusual way.
Their line of conversation may involve repeating your phrases or words back to you or asking the same questions consequently. People with autism will usually only talk about topics that are of interest to them which makes the give and take in communication difficult. They have difficulty interpreting non-verbal forms of communication like facial expressions, hand gestures and other body language. Impaired communication is often seen by signs of delayed language development,
difficulties initiating and sustaining conversations and stereotyped and repetitive use of language such as repeating phrases from television or sentences heard from other people.
Fig. 2. Copyright (2008) by Child Assessment service, Department of Health, HKSAR
Symptoms
Autism can be identified through a wide variety of communicational interactions as well as cognitive functions from an age of as little as 18 months, but generally begin to show at around 2 to 3 years. It is commonly believed that the latest a child can be diagnosed with autism is 12 months, but this is false as signs may appear or only be recognised later on in life, with the large majority of times being in early childhood. These signs may express themselves as extreme difficulty in both verbal as well as non-verbal communication, lack of interest in their surroundings or extreme concentration on a specific object or action, or even a lack of understanding social cues such as body language or tone of voice. These are all telltale signs that someone may have autism but do not necessarily specify at what level their autism is, as many of the symptoms are common across all three levels.
Due to the nature of autism, in that it affects everyone differently, it is quite difficult to set specific and accurate symptoms for sufferers of the mental illness, as they range from very mild to extremely severe. The most common tipoff that autism is present in a child is the lack of three specific skill sets, which are social skills, communication and behavior that is different from people who do not suffer from Autism. For example, a child with autism will have a hard time forming bonds with the society around him/her, even direct ones such as caregivers. This can clearly be seen by the difference in social interaction between a child with autism and one without: the autistic child would want to stay away from the caregiver and situations where it would be uncertain, while the latter would more likely approach the caregiver and open up to new experiences, growing and learning. This can even be seen in other ways such as a lack of a response when their name is called, no interest in playing with other children, preference to being alone, a complete rejection of physical contact, and most worrying of all, a lack of understanding of emotion; both the child’s own and those of others around them.
At this point it is clear that autism is visible from a very early point in a child’s life, but it can affect more than just pure social interaction. In fact, it can inhibit or completely shut off communication which will further isolate the child from developing and achieving in their personal and social lives. A small percentage of children with autism begin talking later on in life, but most have the same problems with speech which are delayed speech, a tendency to use one specific tone at all times, echolalia (the repetition of a phrase over and over), numerous problems with pronouns, rarely using gestures and not responding to them (pointing and waving), inability to recognize sarcasm or humour, and not being able to hold a conversation while staying on topic, even when answering questions. These disadvantages caused by autism would clearly present difficulties in the child’s early life and may snowball into complete muteness during later life, or at best very minimal and unrefined communication.
The earlier the signs of autism are seen the earlier it can be diagnosed and treated, which makes it exponentially more effective. This means it is of the utmost importance to notice and report these signs to a psychiatrist as soon as they are seen. Some milestones are hints that the child may potentially have autism, and if they aren’t met it is recommended to go see the child’s pediatrician regarding said milestones. The child should smile by 6 months at the latest, imitate expressions and sounds from the primary caregiver by 9 months, display gestures by 14 months, speak in single words by 16 months and more than 2 words by 24 months, and must be able to play by 18 months else they are extremely likely to have some degree of autism. It is not shameful to seek help as the earlier the child is assisted in developing their lack of skills, the higher the chance of them leading a normal life and achieving their own potential.
What are the Possible Causes?
Autism is both caused by a wide variety of factors as well as none that we can specifically point out, meaning we don’t really know or have valid evidence of what exactly causes it, yet it is generally believed that genetic factors predominate as the main cause of autism. Numerous potential causes of autism have been suggested and proposed, yet none hold enough sufficient evidence to be names the actual cause of the mental illness, only supporting factors that increase the risk of it developing, such as direct blood ties with a sufferer or agents that cause child defects (pregnant mothers smoking or drinking). Other potentialities with little to no scientific backing have even been presented, such as child immunization and over caring for an infant, but multiple epidemiological studies (studies showing the distribution and determinants of health and disease conditions in specified populations) have proven a lack of scientific evidence connecting said causes to the development of autism.
Experts are still uncertain about the cause of it, but most agree that it is caused by multiple reasons and unique circumstances- which include environmental, biological and genetic factors- all of which would make a child more prone to developing autism.
Improving ASD
Over the decades, there has been a strong demand for effective and appropriate interventions for infants, toddlers and children for the diagnosis for ASD. We want to further this research to inform people that because Autism is a spectrum, there is space to improve. With the right treatment and therapy and with the proper motivation in mind, a child can genuinely get his/her symptoms decreased from certain levels of severity. The first thing we have to improve in is our knowledge and awareness of the disorder itself, then we can start working on the development of ASD.
Diagnosis
ASD diagnosis is a two-stage process. The first stage consists of general developmental screening during appointments with a pediatrician or an early health care provider. Children who show some developmental problems are required to take additional evaluations with the doctor.
The second stage known as Comprehensive diagnostic evaluation involves an in- depth evaluation by professionals in different specialties. The doctors confirm in the second stage if a child is diagnosed with autism or any other developmental disorders.
Children with autism spectrum disorder can commonly be diagnosed by age 2, although research suggests that some screening tests can be beneficial at 18 months. The earlier the diagnosis begins; the sooner treatments may be helpful. Early interventions can reduce or prevent much serious disabilities associated with ASD. Early intervention can also improve a child’s IQ, language, and every day functional skills which are also called adaptive behavior.
Screening
The advantage of screening for ASD is that diagnosing ASD at an earlier age may lead to early intervention and treatment, which includes behavioral, educational, and speech therapy. There is proof that early intervention and treatment may steer to better results in children with autism because the symptoms were detected early. The appropriate child checkup includes a developmental screening test, with specific ASD screening at 12 and 18 months. One must note that screening and diagnosis are not the same for ASD, as screening notifies the doctor if a child is required with more testing.
Researchers have found no proven cure for Autism spectrum disorder, but some of the interventions can be beneficial and helpful to improve ASD.
Treatment
Early intervention
Research has shown that intensive behavioral therapy during pre-school or childhood can improve cognitive and language skills significantly in young children with ASD. The American Academy of Pediatrics has identified a few common features for an effective intervention program. These include:
• Providing children with at least 25 hours a week and 12 months a year with focused and challenging learning activities at the correct developmental level the child is on.
• Encouraging activities involving the development of children should help to achieve a specific learning goal. These include speaking, playing games, etc.
• Providing a degree of routine such as schedules of activities for the child and to reduce distractions
• Measuring the development and growth of a child and reinforcing every positive behavior made by the child
• Teaching social skills like communicating with peers or family, and making and maintaining eye contact while talking
• Guiding the child while making teaching new skills and teaching how to react to new situations and settings.
Medications
Some medications can reduce the symptoms that causes an obstacle for the child. During school or at home. Doctors prescribe medications off-label if they are useful for the treatment of Autism spectrum disorder. However, an elaborated study is conducted before hand to be sure that these prescriptions for the children and teens with ASD are safe and effective.
The only medications approved by the U.S Food and Drug Administration (FDA) to treat ASD are antipsychotics risperidone (Risperdal) and aripripazole (Abilify). They are used to treat schizophrenia, bipolar disorder and irritability such as harming acts or temper tantrums in Autism spectrum disorder. It is taken either by mouth or injection in the muscle; this effect lasts for about two weeks. It is used in children aging from 5 to 16.
The medications provided off label by doctors for children with ASD are:
• Antipsychotic medications: These medications are prescribed to serious cases of schizophrenia. However, it helps to calm a child with ASD by reducing his tempers or thoughts of self-harm.
• Antidepressant medications: These medications are prescribed to treat depression and anxiety, but they reduce repetitive behaviors in ASD. These antidepressants also help to control aggressive behavior and anxiety in children with ASD. However, researchers are still not sure whether these antidepressants are helpful for ASD, as they compared it with placebos. Fluoxetine (Prozac) or sertraline (Zoloft) are the two examples of antidepressants.
• Stimulant medications: These medications are safe for ADHD and treating hyperactivity in ASD. Methylphenidate (Ritalin) is an example of stimulant medication
Therapies
Since every child in the spectrum differs in severity and types, there are certain therapies for specific cases that are known to improve speech, learning and social skills for children with ASD. Certain severity levels have certain therapies that are needed and will work.
Applied behavior analysis (ABA)
ABA is a therapy known for enhancing behavior modification and its procedures are attained from the concepts of operant learning which are put forth to enhance socially adaptive behavior and acquisition of new skills through in-depth practice and reinforcement.
ABA helps in understanding the functions of behavior, and how the environment affects the behavior. It develops language and communication skills, and enhances attention, focus and memory. It teaches motor, social and verbal behavior. These skills are taught through observation and reinforcement.
The therapy starts with treatment plans which narrows the purpose and function of behavioral deficits, selecting the convenient techniques, and examination and modification of treatment through collecting and analyzing data. ABA tries to change the behavior by:
1. Analyzing the relationship between targeted behavior and the environment
2. Develop socially acceptable substitutes for uncommon behavior. This theory is related to operant learning as the techniques of operant learning are used in ABA treatment for ASD. Some of the strategies are:
3. Using of positive reinforcement like toys, snack, or appraisal
4. Shaping: when a behavior is somewhat approximate to the desired behavior, the child should be reinforced. Behavior which are almost positive are the steps towards target behavior.
5. Limiting distractions to decrease dependence
6. Extinction: limit or take off reinforcement to maintain behavior which are acceptable
Sensory integration therapy (SIT)
The foundation of concepts of the sensory integration therapy are based on research areas of neuroscience, developmental psychology, education, and occupational therapy. The aim of sensory integration therapy is to enhance the ability of the brain to handle sensory information, so that the child might adapt to the daily functions and responses well. Some examples of activities include dancing to music, crawling through tunnels and balancing on a beam. The child is mentored through all these activities that the stimulations are challenging. Latest studies indicate that sensory integration therapy improves daily activities in children with autism. Studies found out that this therapy is successful in easing sensory difficulties like repetitive behavior, poor eye contact and more.
The therapist gets the child used to stimuli like touch or sound and plan games, so the child does not feel distressed. Sensory integration therapy involves placing a child in a room which is precisely designed to trigger and challenge all the senses of the child. During the session, the therapist mainly focuses on the child to encourage movement within the room. Children with autism have a tough time listening when they are preoccupied with something. Hence, they struggle in receiving information through more than one sense simultaneously. Physicians who treat children with autism believe that these difficulties arise because of the difference between the brain of a child with autism from others.
Research suggests that sensory information which is received from the environment is critical, and the interaction between the child and the environment shapes the brain and influences the child’s learning.
A study was conducted by occupational therapists at the Philadelphia Jefferson School of Health Professions to. In their study, the researchers combined two measures to enhance the reliability of their test. They used the Sensory Integration Fidelity Measure which was developed recently to ensure that each therapist carried out the intervention in a manner which was consistent with its principles. They also used a Goal Attainment Scale to measure the benefits objectively against the parent-set targets for each child.
A parent of a child who wakes during the night due to severe sound sensitivity could set the goal of improving tolerance of ordinary noises and sleeping through the night. Researchers randomly appointed 32 children with autism ranging from age 4 to 8 in one of the two groups. After 10 weeks, the control group received regular care with standard speech, and other therapies for autism spectrum disorder. The experimental group also received the regular care along with 3 hours per week of sensory integration therapy.
At the end of the study, it was analyzed that the children in the experimental group scored higher in achieving their goals and required less support in self-care and socializing from their parents.
Verbal behavior therapy (VBT)
Verbal behavioral therapy is based on the concepts of applied behavioral analysis, and it teaches communications and language by connecting words with their purposes. This therapy does not focus on the words, rather it focuses on why these words are used and how they are helpful in communicating. The therapy instead focuses on four-word types, which are mand, tact, intraverbal and echoic.
• The mand is a request a child makes, such as saying “cookie” to ask for it.
• The tact is commenting on what the child sees in the environment, such as saying “airplane” when s/he sees an airplane.
• Intraverbal is responding to a question asked by someone. For example, a child is asked “what is your name”? The child responds with “My name is Alice”.
• Echoic is repeating a word twice or more times, which is appreciated by the therapist.
The VBT program is a well-established program intended to teach quick and expressive speech acquisition. The therapist must arrange for reinforcement items which are then combined with the specific sounds observed to be produced by the child. The child is then asked to copy a sound to access to the preferred object. If the child is unable to imitate the target sounds, then he is rewarded for any vocal response to increase the sound production. Learners are taught to communicate verbally and non-verbally using the four types of words. In other words, the techniques can be used to speak someone who is not verbal.
The key elements of the VB therapy are:
• Strong focus on language development.
• Errorless learning by means of immediate and frequent instructions, which are reduced after success.
• Frequent and immediate reinforcement.
• Situations and instructions varied to support the interest of individuals.
Relationship development therapy (RDI)
Relationship development therapy is a parent-based treatment for the diagnosis of autisms spectrum disorder and its main goal is to teach motivational, social and emotional skills to share interaction, which is fundamental in autism.
RDI helps people with autism to form personal relationships by strengthening the building blocks of social relationships, including the ability to form an emotional bond and share experiences with others. It involves motivation building and teaching skills step by step and the strategies are based on the current age and level of skills of the child. The parent or therapist uses a set of goals that are relevant for the development.
The therapy builds on the idea that dynamic intelligence is essential for improving the quality of life for people with autism. The meaning of dynamic intelligence is to understand different views, cope up with changes and combine information from sources like sights, sounds, and other senses.
The first objective is to build a participation relationship between parents and children, with the child as a cognitive beginner. Once this relationship has been established, the family proceeds through a series of developmental goals for the child. During the sessions, the parent guides the child under the supervision of the consultant in various activities, such as playing games or playing a musical instrument. All activities are aimed at parents connecting with their children to help them interact more effectively and to communicate their ideas and concerns.