Autism is a lifelong disability that affects the way a person develops socially, communicates and relates to people around them. Autism is often referred to as ASD meaning Autistic Spectrum Disorder but increasingly it is referred to as ASC meaning Autistic Spectrum Condition which is a term I prefer. This is because in my opinion it describes autism more accurately. Autism is a spectrum of conditions that vary from a very mild disability where a person functions well within society, successfully having a job and a family to a condition that is almost totally disabling.
ASC ranges from relatively mild to severe, with a wide variation in between. Those at the severest end will need constant adult care. They will never develop language or be able to care for themselves. At the mildest end people manage their own lives, marry and have families, they can be bright enough to become professionals, but most have difficulties relating to others.
Where children are at the severe end of the Autistic Spectrum it is usually obvious and medical staff are easily able to make a diagnosis. Therefore the focus here is on the mild end of ASD where parents are often baffled by their children’s behaviour.
Some Types of Autism
Those diagnosed with autism are not an homogenous group. Increasingly the term autism seems to describe a range of difficulties. Here I very briefly describe diagnostic terms that teachers are most likely to find in their classrooms.
Autistic Spectrum disorder
This is what some will call ‘full’ autism. Onset will have been before the age of three years and in many ways is one of the easier forms of autism to diagnose. These children do not usually develop language or the ability to communicate non-verbally. They often have repetitive actions; they require consistency and sameness in routines and people. This group can sometimes be helped to develop a degree of independence with the right sort of support, but many need care for all of their lives and may never become independent.
Other individuals in the group presenting with severe autism if given the right sort of consistent and structured support can develop language and can eventually lead satisfying lives. But mostly they usually need to be in supported environments for all of their lives although some do manage to earn a living.
Asperger’s syndrome
Children with mild autism are often diagnosed as having Asperger’s Syndrome the symptoms are slightly different to autism but most professional agree that the two are closely linked.
Children with Asperger’s syndrome usually have the full range of intellectual abilities their intelligence can be average or above average. They usually want friends but just can’t quite fathom how to make and keep friends and to be successful socially with peers.
Not only do they often not display a range of emotions in their language or on their own faces, but they usually struggle to understand others’ emotions, nor can they automatically read facial expressions or body language of others.
These young people acquire language at the normal rate; they can have an excellent vocabulary but have some difficulty in understanding complex and abstract language. Spoken language, especially if it is abstract or idiomatic, may be beyond their ability to understand. Parents and teachers need to be aware that they may not assume that what a child with Asperger’s Syndrome can recite is actually understood, it may simply be that it has been rote learned.
Motor skills
Motor skill difficulties are often comorbid with Asperger’s Syndrome. As children they have a developmental coordination delay which means they may find difficulties with learning to fasten buttons, dressing and feeding themselves and learning to write. The range of motor skill difficulties evident with this aspect of Asperger’s Syndrome is described on my page on dyspraxia.
Sensory Processing
Sensory processing issues is another factor that may be comorbid with Asperger’s disorder. Sensory over load is something that has been acknowledged more in recent years. Any of the senses can be affected, touch, taste, sight, sound and smell.
Children can be overwhelmed by smells that to most people are relatively mild and wouldn’t normally be noticed. For children in school the noise from the school canteen at lunch times can be so overwhelming that they are unable to go into the room. The imprint from the slightest touch can remain for hours. Some clothing feels so rough that it is intolerable.
Concentration in busy noisy classrooms is very difficult for many of these young people and they prefer to be able to work alone. They may seek solitude at break times.
Pervasive development disorder
This group displays many of the characteristics of the Asperger’s group but to a lesser extent. Again onset is said to be after the age of 3 years but many mothers say that they always knew there was ‘something different’ about their child but again their concerns were dismissed by professionals. PDD is often described as ‘atypical autism’. Some doctors may diagnose the symptoms as PDD/NOS. NOS stands for Not Otherwise Specified. Autism at this end of the spectrum is often difficult to diagnose, understandably doctors do not want to incorrectly label a child as having a lifelong condition that is not reversible and quite rightly they want to be certain. Some of the characteristics that this group display are relatively mild, fewer in number than other’s with ASD. This group can almost always be helped with the right sort of support and often go on to lead reasonably normal independent lives.
Pathological Demand Avoidance
This is a relatively recent addition to the ASC umbrella and it is controversial for a number of reasons. Not all professionals in the field agree that it sits within the ASC framework but is a separate condition. Some practitioners will diagnose but others will not. It is not in the DSM V classification.
With PDA there is apparent social awareness but the behaviour is often uninhibited. I can remember going into a class and hearing a very clear statement from the four-year-old I was due to see saying, ‘I really don’t think my mother would like me to do that’ when he had been asked to prepare for a session on the carpet. The Demand avoidance often dominates and appears to be an obsessional preoccupation. Even simple tasks such as being told it is time to get out of bed.
Characteristic features of Autism
Below are described some of the difficulties that sit within the ASC label.
A key problem for children and adults with ASC is that they are often unable to relate to others in a meaningful way. Their ability to develop friendships is impaired as is their capacity to ‘read others’ and understand other people’s feelings.
Another key difficulty is that they suffer from anxiety that is so extreme that it may be a barrier to normal functioning. The way they react when anxious and fearful can lead to behaviour that is socially unacceptable. People with ASC can often have accompanying learning disabilities but everyone with the condition shares a difficulty in making sense of the social world.
The three main areas that are problematic are a child’s social, communication and interaction skills. This is seen in the following ways as difficulties with:
- Predicting the behaviour of others, a consequence of this is that as young children those with ASC avoid other people, peers and adults because the unpredictability is frightening. They become more confident with familiar adults, particularly those who help to mediate between them and others. These children remain adult focused to have their needs met and may avoid peers all of their school lives although this is rare.
- Predicting the intentions of others. Most people do this by reading body language and listening to voice intonation. These are not skills those with an ASC automatically learn, (but it can be taught).
- Understanding the motives of others. These children tend to see life in a very ‘black and white’ way with few shades of grey. Others motives are mysterious and confusing.
- Understanding their own and other’s emotions which leads to a lack of empathy.
- Understanding the impact of their behaviour on the feelings of others this is because they do not automatically develop a ‘theory of mind’.
- A lack of a ‘theory of mind’ sometimes leads to conversations that may be incomprehensible to all concerned. This is because they fail to develop an understanding that others might already have some knowledge that is different to theirs and may lead to a different perspective.
- Making and maintaining same age friendships this is partly because they cannot read how interested others might (or might not) be in what they are saying, they relentlessly pursue their own idiosyncratic interests and have no idea how to anticipate what others might think of their actions. They cannot engage in other children’s games because they have no interest in them. Often they are utterly bemused by the fact that other children are not interested in the same things they are. One thirteen year old whose parents and teachers were concerned about her isolation told me ‘I have to watch my friends or they disappear, I have so many interesting things to tell them but they just go!’ This group of young people will tell me they have plenty of friends but are often unable to name more than one, but to them that is enough.
- Understanding social interaction, research indicates that as babies a key difference in these children is that they don’t look at their mother’s faces and through this learn about the nonverbal communication that is delivered through facial expression. Therefore they have poor eye contact and fail to learn about the turn taking that happens in normal interactions. They remain apparently very ego centric.
- They do not easily or automatically learn the rules of social order that the other children seem to understand almost without being taught. This means that a child with an ASC can get confused by or just ignore social rules and conventions that are implicit yet automatically understood by others.
Socially these children are also vulnerable because they may not understand deception or pretence. Once at secondary school they may fall prey to older children who may use them for their own ends and the ASC child may just be glad to have a friend not realising some of the subtleties of interaction and intention and so find themselves in difficulties.
Diagnosis
ASC and Asperger’s are medically diagnosed conditions. There is no test such as a blood test to identify an ASC condition, a diagnosis is a matter of opinion, arrived at through gathering information from those who know the child and considering that information against a set of criteria. Best practice is that the doctor will consult with others such as parents, teachers and educational psychologists, although very experienced paediatricians will often diagnose based upon what parents tell them. This group may not be diagnosed until they are in their teens. This group can almost always be helped with the right sort of support and often go on to lead reasonably normal independent lives.
Reference
Jacquelyn Bertrand, PhD*, Audrey Mars, MD , Coleen Boyle, PhD*, Frank Bove, ScD§, Marshalyn Yeargin-Allsopp, MD*, and Pierre Decoufle, ScD* Prevalence of Autism in a United States Population: The Brick Township, New Jersey, Investigation.
PEDIATRICS Vol. 108 No. 5 November 2001, pp. 1155-1161
While I would not diagnose an ASC, I can contribute to an assessment and advise on how to support children and young people where ASC has been diagnosed or there are concerns that ASC may be present.
For an appointment you can email me at teresa.bliss@btinternet.com