Autism Spectrum Disorder (ASD) – Primary and Secondary Symptoms

By: Dr. AnalpaParanjpe,PhD

Autism spectrum disorder (ASD) is a developmental disability that can cause significant social, behavioral andcommunication challenges. Most often individuals with ASD may look like other people, but may communicate, interact, behave, and learn in ways that are different from most other individuals. The learning, thinking, and problem-solving abilities of individuals with ASD can range from gifted to severely challenged. Some individuals with ASD need a lot of help in their daily lives while others need less.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) released by the American Psychiatric Association in 2013  is now the standard reference that healthcare providers use to diagnose mental and behavioral conditions, including autism, now termed as Autism Spectrum Disorder (ASD). A diagnosis of ASD now includes several conditions that used to be diagnosed separately in DSM-4: autistic disorder, pervasive developmental disorder not otherwise specified (PDD-NOS), and Asperger syndrome. These conditions are now all called Autism Spectrum Disorder (ASD).

Individuals working with ASD need to be aware about ‘normal’ developmental milestones. They also need to observe the child’s behavior very carefully. Another important aspect is conducting a hearing test to rule out any physical impairment. A child on autism spectrum may not respond to name, or instructions. One has to ensure that s/he hears well before arriving at a diagnosis.

Caregivers must also keep a few pointers in mind. Keeping an on-going diary with observation notes based on the following questions could be a starting point and will better help in further diagnosis. These observations must be noted from as early as 3-4 months of age, especially so if genetics is involved.

Sometimes some of the symptoms may be observed sporadically, not consistently. In such cases too, keeping a detailed record helps in pointing to comorbidity. (The response in bracket may point out to ‘at-risk’ and a cause of concern). Importance of early intervention can be reiterated here.The brain responds to the therapy by forming new neuronal connections in the brain with new concept learning.  Inputs in areas of concern may alleviatethe problem.

1. Whether the child starts babbling by age of 5 months. {Babbling is a stage in child development and a state in language acquisition during which an infant appears to be experimenting with uttering articulate sounds, but does not yet produce any recognizable words. Sounds like Ma-ma, da-da, boooo, etc.}(NO)
2. Whether the child communicates mostly by screaming, tantrums (YES)
3. Observe whether the child gives eye contact between 6-9months. Gives social smile in recognition to known adults (NO)
4. Does the child reciprocate sounds, responds to peek-a-boo (NO)
5. Lacks play skills (YES)
6. Does the child respond to own name by age of 10 months (NO)
7. By 12 months does the child deliberately point at things, waves, or grasps objects (NO)
8. How sensitive is the child to touch (cuddle)?  Or noise (loud whistle, banging) (MORE OR LESS SENSITIVE- both are cause of concern)
9. Does the child’s focus fixate on certain objects – disregarding other objects, individuals (YES)
10. Does the child indulge in repetitive movements like rocking, twirling, hand flapping (YES)
11. Does the child stick to routines, is set in their ways (YES)
12.  Does the child have limited vocabulary (YES)
13.  Throw prolonged temper tantrums (YES)
14. Did the child exhibit normal development till 18-24 months and show regression thereafter (YES)

Keeping a record of responses to these questions every 3 months is important.

Prevalence:

One question that keeps on cropping up frequently is about the prevalence of Autism. According to some researchers, the increasing number of diagnosed cases of ASD may be due to a broader definition of autism which was changed in 1994 and then in 2013

According to the new definition, Autism Spectrum Disorder (ASD) is distinguished by a pattern of symptoms rather than a single symptom, which manifest before 3 years of age.

Recent Research:

Researchers are trying tofind out if ASD can be diagnosed at an age earlier than 3-4 years.  Some headway was done in longitudinal studies of children suspected of ASD as early as 12 months. But a lot more work needs to be done in this area for better understanding and conclusion.

Signs and Symptoms:

The main characteristics / symptomsof ASD are seen in the following areas:

1. Impairment in social interaction
2. Impairment in communication
3. Restricted interest and Repetitive behavior

1. Impairment in social interaction or Socialization (2 or more)
   1. Difficulty in using non-speech behavior for social interaction (no eye contact, gestures, facial expressions, tone of voice)
   1. Failure to develop peer relationships (inability to interact with peers in a meaningful way)
   1. Lack of spontaneous seeking, for ex. to share enjoyment, interest or achievements. Mostly individual with Autism may approach others only to get their needs fulfilled
   1. Lack social or emotional responding (are not cognizant or not aware of  others’ emotions and cannot reciprocate accordingly)

• Impairment inCommunication (1 or more)
  • Delay (fewwords, specific vocabulary,   lack of prepositions and pronouns); complete lack of spoken language (non-verbal)
  • Difficulty in initiating or continuing conversation (lack topics,ideas, inability to ask questions, or track conversation)
  • Inflexible and repetitive use of language (echolalia)
  • Lack in varied, spontaneous make-believe play (toy kitchen)  or social imitative play (imitating peers)

• Restricted interest and Repetitive, inflexible behavior(1 or more)
  • Rigidity in following of nonfunctional routines (sitting in same chair, same colour cup, same route to school, same routine for the day)
  • Obsession with inflexible and limited interests (cars, fire trucks, trains, flags, etc)
  • Obsession with parts of objects instead of whole object (wheels of a car, instead of the car as a whole)
  • Inflexible and repetitive body movements (rocking back and forth, toe walking, hand flapping, circular movement, twirling, etc)

These are called ‘Self-Stimulatory Behaviours (SSBs)’ also known as ‘Stimming’. Through the SSBs individuals with Autism reward themselvesinternally. These are automatically reinforcing behaviours which do not require or involveother persons for gratification. SSBs also give pleasurable sensory inputs. According to experts the SSBs should not be stopped altogether, but can be curtailed to some extent.

SSBs involve various modalities of inputs, and these can be observed in the child’s behaviour –

S.N.	Modality	Self-Stimulatory Behaviour (SSBs)
1	Body movements	jumping in place, hand flapping, spinning in circles, etc
2	Visual	eye gazing, looking out of the corners of eyes, gazing at hands or fingers or other objects (items that spin, falling items, lined up objects)
3	Auditory	make sounds, noises to hear them, etc.
4	Oral	play with saliva, mouthing objects, grinding teeth, etc.
5	Tactile	needsfavourite materials to touch, hold. Fuzzy, soft items, etc.
6	Smell	smelling hands, picking items and smelling them repetitively, etc.

Keep in mind:

1. Symptoms must be present in the early developmental period (but may not fully manifest until social demands exceed the limited capacities or may be masked by learned strategies in later life).
2. Symptoms should cause clinically significant impairment in social, occupational, or other important areas of current functioning.
3. These disturbances in functioning are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual Disability (ID) and Autism Spectrum Disorder(ASD)frequently co-occur; to make comorbid diagnoses of ASD and ID,social communication should be below that expected for general developmental level.