by Erica Heilman
Parents are usually the first to notice. Their child does not like to
be touched or held. When the child is two years old, he makes some
progress in language skills, only to lose those skills again at 2 1/2.
He's fascinated by the wheels of his toy car, but not by the car itself.
By age three, the signs of autism are hard to ignore.
It is estimated that as many as 2 to 6 in 1,000 children are born
with some degree of autism, which refers to a spectrum of pervasive
developmental disorders that range in severity from mild to severe. The
mildest form in the spectrum is Asberger's disorder, and true autistic
disorder is the most severe form, affecting an estimated 1 in 2,000
children.
As a child and adolescent psychiatrist, Dr. Milton Anderson has
worked with hundreds of autistic children. In the following
conversation, he describes the signs of autism, and offers some sound
advice to parents about treatment and setting realistic expectations for
progress.
What are the characteristics of autistic
disorder?
The first is a problem with nonverbal social communication, or the
quality of how the child communicates with people when he or she is not
using words. That could include the way that he uses his body, or the
way that he expresses emotion with facial expressions, gestures, or eye
contact.
The second component is a delay in language development. This is
measurable by a speech and language pathologist, but it's usually
obvious to parents by the time the child is eighteen months old or so.
Commonly, an autistic child will start off with normal development,
progressing to a couple of word phrases, but then loses those language
milestones at anywhere from eighteen months to 3 years of age. They make
initial progress and then those milestones are lost.
The third cluster of symptoms that make up autistic disorder is
behavioral rigidity. This can include obsessional interest, or a
preoccupation with something very specific or odd. They are often
interested in just the parts of things. For example, while most children
might be very interested in dinosaurs, a child with autistic disorder
might be extremely interested in the vertebrae of dinosaurs.
What causes autism?
The causes of autistic disorder seem to relate to problems in brain
development that occur in either the first or second trimester of
gestation. In most children, if the history is examined closely enough,
there are signs that the disorder is present from birth; if you really
go back through the history with the parents and ask very, very specific
questions about exactly what the child was like early on.
There is a belief among some that autism is
the result of childhood immunizations. What's your response to that?
The loss of language skills in autistic children occurs at a time when a
lot of children are getting immunizations, which has given rise to the
theory that autism is a reaction to the immunizations, or a reaction to
contaminants in immunizations.
This has been hotly debated, and it continues to be a debate. The
vast majority of experts in the field of pervasive developmental
disorders do not believe that this has anything to do with the cause of
autistic disorder.
Can you describe a child who displays
typical behavioral symptoms of autism?
A parent might come to me with a child who is 3 1/2 or 4 years old, who
is having behavioral problems in preschool. He is having trouble getting
along with the other children. I learn he has not liked to be held by
his parents for most of his life, and his hugs are awkward and stiff. He
made fairly normal eye contact in the first six months of life, but
since that time has averted his gaze. The child doesn't like to look at
people, especially people who aren't his parents, and he is often
described by people as "anti-social." In fact, he's more likely to let
you know that he's showing you affection by backing up to you and
leaning against you. He also has difficulty letting you know that he
wants something using gestural language.
How does that child play?
The child will only play by himself. In preschool, the other children
might try to play with him, but he won't engage with them at all. If the
teacher or the other children insist on his participation, he might
become very aggressive in pushing them away. If someone tries to take
away the toy that he is interested in at that time, he may become either
very angry and aggressive or he may cry and take a very long time to
pull himself back together again. He may even kick, bite, or spit.
What about his language skills?
He may seem to have his own private language, or it may simply have lots
of jargon, words that don't make any sense at all. It may have some of
the musical qualities of regular language, but it doesn't make sense. At
times he may be able to communicate something with words, but the next
several hundred words are essentially jargon-filled babbling. At other
times, you say something to the child and he may simply say it right
back to you, which is called "echolalia."
As children get older, some may develop what is called "palilalia."
This usually occurs in higher-functioning autistic children, such as
children with Asperger's disorder. This is where the child says a
sentence and then whispers the same sentence under their breath.
For children who do develop better language, it's very common to only
speak rote language. For example, they may watch the movie Toy Story and
favorite parts of that movie will be well-memorized, then repeated over
and over and over.
How is autism first diagnosed?
The pediatrician, of course, is the first doctor a parent should speak
with. The parent may ask them, "Do you think my child has autistic
disorder?" and some pediatricians will say, "No, no, they're going to
grow out of this. Let's wait and see." Some parents may want to go with
the wait-and-see method, and others will proceed to an evaluation rather
quickly and just get the question answered.
Whether the first or the second method is right depends upon how old
the child is. If the child is one year old, then waiting and seeing, I
would say, is okay. If the child is two years old, then the second
method –getting the evaluation promptly –is very important.
Why is the age a diagnosis is made
important?
Early intervention is very important. At the earliest, usually, eighteen
months to two years is when we can be certain of a diagnosis. And that's
pushing it to be sure. But it's never too early to start intervention,
even if you're not certain about the diagnosis. The likelihood of
successful improvement in communication disorders is higher with earlier
intervention.
What should parents look for in a treatment
program?
A treatment program really should target both language and nonverbal
social communication skills.
As far as treating the nonverbal social communication disorders,
there are a few different methods to choose from. What good methods
share is intensity of treatment; spending a lot of time, pretty much
each day, with the child.
Who should be included in the child's
treatment program?
The parents and the child. The child's pediatrician. A developmental
pediatrician. An education specialist. A speech and language
pathologist. An occupational therapist. Sometimes a physical therapist,
depending on the child's coordination and other physical capacities.
Are medications used in the treatment of
autism?
Medications are often used in the treatment of autism as children get
older. They are usually not used prior to the age of six to nine years.
In general, the focus of medications has been to assist in the
management of behavioral problems when behavioral interventions by
themselves have been ineffective.
In the last five years there has been some consistent research that
has showed some modest but significant improvements in the core symptoms
of autism with the use of a group of medications known as the atypical
neuroleptics. Recently, there was a large study that reported on the use
of one of these medications for aggression in children with autistic
disorder. There also have been smaller studies that have received less
hoopla on improvement in the core symptoms of autism, using the same
medication.
What should parents expect a treatment
program to achieve?
Parents should not expect some miraculous cure at any point. Treatment
is going to be long-term and potentially, lifelong. It may be less
intensive later, in high-school age years, depending on how well the
child does. But there is going to be some therapeutic activity going on
in the child's life for many years.
Occasionally a child is reported to have a "complete remission." I
have not seen that yet in my practice. I have seen children who have
improved remarkably, but I have not yet seen a complete remission.
A significant number of children with pervasive
developmental-spectrum disorders live independently. People at the high
functioning end of the autism spectrum disorder, such as Asperger's
disorder, essentially always live independently. The severe autistic
spectrum disorders-whether they live independently-has more to do with
the degree of intellectual impairment than anything else. If you have an
average IQ, the likelihood of living independently if you also have
autistic disorder is fair. If you have an IQ of 50, the likelihood of
living independently is very low.
Can you describe some aspect of autistic
children that you find particularly interesting?
They're often very good at cutting through blather and at poking fun of
social niceties that don't really make a lot of sense.
People with autism-spectrum disorders are a delight when they can
trust you and it's in an environment that is tolerable for them; the
lights aren't too bright, it's not too crowded, people aren't too loud
and obnoxious.
What would you suggest to parents who
suspect their child has autism?
The first thing they should do, especially if their child is three or
under, is to speak to their pediatrician. They can also contact the
Autism Society of America to learn more about the disorder, or go to the
Society's Web site and do some reading.
Dr. Milton Anderson is a child and adolescent psychiatrist at
Ochsner Clinic Foundation in New Orleans.
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World News Tonight
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