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Autism: Clinical Paper

Three year-old John presents with his mother to the office today because he "Just won't talk me, and won't play with his brother."

With further questioning, she tells me that he does not engage in any verbal play, dress-up play, or appropriate play with toys. The only words he says are words he hears on the television, or he repeats words back that he has heard. He does not come to her for hugs and kisses. This has been going on for about a year, but she thought he would just "grow out of it".

Upon interacting with John, he will not meet my gaze, and will not respond to questions posed to him. His right hand "flaps" in an intermittent pattern.

In observing John, he has taken one stuffed animal from the toy area, and is repeatedly hitting it against the floor. When I went to redirect John, he dropped to the floor, crying.

This is a classical presentation one might see from a child with autistic disorder, As can be seen from the following excerpt from the Diagnostic and Statistical Manual of Mental disorders .

Autism, as defined in the DSM-IV is a Pervasive Developmental Disorder (PDD). PDD's are those in which the child has marked deficits in their development, when compared to the age appropriate norms, either physical and/or mental.

The DSM-IV notes three areas from which diagnosis must be made , social interaction, communication, and behavior/motor activity. Additionally, cognitive impairments are commonly seen. The diagnostic criteria from the DSM-IV are as follows:

A total of six (or more) items form (1), (2) and (3), with at least two from (1) and one each from (2) and (3):
1. qualitative impairment in social interaction, as manifested by at least two of the following:
  1. marked impairment in the use of multiple nonverbal behaviors such as eye-to eye gaze, facial expression, body postures, and gestures to regulate social interaction
  2. failure to develop peer relationships appropriate to developmental level
  3. a lack of spontaneous seeking to share enjoyment, interests, ore achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)
  4. lack of social or emotional reciprocity
2. qualitative impairments in communication as manifested by at least one of the following:
  1. delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
  2. in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
  3. stereotyped and repetitive use of language or idiosyncratic language
  4. lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
3. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
  1. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
  2. apparently inflexible adherence to specific nonfunctional routines or rituals
  3. stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
  4. persistent preoccupation with parts of objects
Delays or abnormal functioning in at lest one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.
The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder

Symptoms may manifest in early infancy, with the infant shying away from the parents touch, not responding to a parent who returns after an absence, and inappropriate gaze behavior ("Autism - Part I", 1997; Klin and Volkmar, 1999, p. 253). The child may fail to meet early language and other developmental milestones. This is the time when most parents begin to become aware that there is something "different". According to Klin and Volkmar , there is often up to a 3-year delay between the report of symptoms to physicians and diagnosis of autism, which is usually made at around age five. The age of the child make a marked difference in the perceived severity of the disorder.

Wing (1997) notes, that when evaluating the behavior of an Autistic person, their age must be kept in mind. It tends to be worse from ages 2 through 5, and then improve from 6 through 10 years of age. It often worsens again in adolescents and young adults, and finally calming back down as they grow older.

Brown (1999) also states that the majority of those with autism, as they get older, take on the negative symptoms of schizophrenia, such as withdrawal, flattened affect, and poverty of thought.

In regards to social aspects, Murray (1996) suggests that the child with autism will present with self-absorption, and rather than forming attachments to persons, may form an obsessive attachment to an inanimate object. Additionally, even the highest functioning Autistic persons have difficulty making and maintaining friendships, showing empathy, and understanding what is expected in social situations . When in a room with other people, the person with autism will, instead of engaging in social contact, involve themselves in solitary activities, generally with an inanimate object. When they are forced into a group, they have difficulty making eye contact with others, or directly communicating with others. This carries over into their play.

The play of the Autistic child tends to be solitary. They do not wish to engage with others in play, their play is less mature, less creative, and they use fewer toys than non-handicapped children. Additionally, when they did play with toys, their play was much more likely to be inappropriate, either aggressive or self-stimulatory (Retting, 1994). They are also unable to stop their play at the request of others.

Autistic children focus strongly on their task at hand. To attempt to change their focus of play, for instance, before they are ready to can create an emotional crisis ("Autism - Part I", 1997). These same crises can occur with nearly any change, from something as simple as adding new furniture to the house to changing their daily routine. On the other hand, they are highly distractible, and have difficult paying attention for periods of time (Olley & Gutentag, 1999). Both the crisis and distractibility have a wide variety of behavioral effects.

Behaviorally, children with autism may display self-injurious behavior, non-compliance, and aggression, over- and under- reaction to stimuli and self-stimulation (often in the form of repetitive movements) (Gresham, Beebe-Frankenberger, & MacMillan, 1999; Olley and Gutentag, 1999). They may engage activities ranging from hand-flapping to repetitive sounds to complex repetitive body maneuvers to biting, hitting or scratching themselves. Much of this may be attributed to their lack of ability to communicate their needs and desires.

When looking at verbal skills, Murray (1996) also notes that fully one-half of autistic children are nonverbal. Others' speech may simply consist of echolalia. He notes that age 5 is generally considered the milestone for the development of usable speech in Autistic children. When speech is present, turn taking seems to be a foreign concept, and speech patterns and intonations are odd (Klin and Volkmar, 1999, p. 254). This speech deficit is beyond what would be expected from their cognitive level.

Cognitively, the majority of persons, about 75%, with autism fall into the category of Mental Retardation. There are additionally about 10% of those persons with autism that fall into the category known as Savant ("Autism - Part I," 1997). These persons have a single ability that is extraordinary, such as mathematical calculations or musical ability or artistic ability. The common perception of a Savant is Dustin Hoffman's apt portrayal in the movie "Rainman." However, It has been questioned if this number of persons represented as mentally retarded is abnormally high, due to interfering effects of the other symptoms of autism on the testing process. (Edelson, Edelson, & Jung, 1998). Testing may also be impaired by other medical or comorbid psychiatric disorders.

Autism Presents comorbidly with a number of other psychiatric disorders, further compounding diagnosis, such as Tourette's syndrome, obsessive-compulsive disorder, and bipolar disorder (Hellings, 2000). Tsai (1999) gives the following Information regarding a review of literature of comorbidity of specific symptoms in persons with autism:

64% had poor attention or concentration;
36% to 48% were hyperactive;
43% to 88% showed morbid or unusual preoccupation;
37% exhibited obsessive phenomena;
16% to 6% showed compulsions or rituals;
50% to 89% demonstrated stereotyped utterances;
68% to 74% exhibited stereotyped mannerisms;
17% to 74% had anxiety or fears;
9% to 44% showed depressive mood, irritability agitation and inappropriate affect;
11% had sleep problems; 24% to 43% had a history of self-injury;
and 8% presented with tics.

Fombonne, Mazaubrun, Cans, & Grandjean, 1997, in their comprehensive study, also note the following medical conditions that can lead to autism: Tuberous sclerosis, chromosomal abnormalities including fragile X, cerebral palsy, congenital rubella, sensory impairments, and Down's syndrome. Additionally, approximately 25% of those with autism also have Epilepsy, and it more common in the more severely impaired (Autism Society of America, 1999; Murray, 1996). Sensorially, Blindness and Deafness are found at a higher rate than expected within the Autistic population (Brown, 1999), and there may be hyper- or hypo-sensitivities to sight hearing, touch, smell or taste (Autism Society of America, 1999).

Unless a person has a very clear picture of autism, there is controversy regarding the diagnosis at the less severe stages.

The boundaries of autism as diagnosis are so vague that is presence may be a matter of degree. Many children (and adults) have the symptoms only milder forms, some of which may be accommodated by the APA's diagnosis of pervasive developmental disorder not otherwise specified. In some cases, mild autism may be difficult to distinguish from personality disorders such as schizoid or obsessional personality or even from certain kinds of personal eccentricity and social awkwardness. ("Autism - Part I," 1997)

And

Current attempts to identify specific syndromes within the autistic spectrums, including those used in the ICD-10 and DSM-IV, are unsatisfactory. The criteria for distinguishing subgroups tend to be arbitrary, and are difficult to apply and unhelpful in clinical practice. The clinical picture can change with increasing age and in different environments. (Wing, 1997)

Although the clinical picture can change, and there can be some overlap between diagnoses, that is not unique to autism. The diagnosis of mental disorders is an art form, and will not be an exact science within the foreseeable future. We should never be afraid to admit that a diagnosis may have been wrong, and that a change may be appropriate if necessary as a person ages. When the diagnosis is on the edge of two different disorders, we can take a hint from the field of education, where the requirement is "least restrictive". We can always make a diagnosis "worse" if necessary, but we need to keep in mind the family, society, stigma, educational placement, and treatment that will be required dependent on our diagnosis.