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Article Index
Autism: Clinical Paper
Social Aspects
Incidence and Prevalence
Etiology and Pathogenesis
Prognosis
Physiologically Based Approaches
All Pages

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".

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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 (4th ed) (DSM-IV).

Autism, as defined in the DSM-IV (APA, 1994, p. 66-71) 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 (APA, pp 70-71), social interaction, communication, and behavior/motor activity. Additionally, cognitive impairments are commonly seen. The diagnostic criteria from the DSM-IV are as follows:

1. 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
2. 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.
3. 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 (1999, p. 252), 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.

Disorders - Autism