Coping With Autism

Diagnosis: Asperger's and Pervasive Developmental Disorders

This article describes the actual symptoms of Autism, Asperger's, and PDD, as well as the clinicians' diagnostic and assessment processes.

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What Is Autism?

Autism or the PDD spectrum includes Asperger's, PPD-not Otherwise Specified (PDD-NOS), and full-blown Autism.  The main difference is the combination, number, and severity of symptoms.  This range of symptoms includes

• Impairment in social interaction and communication

• Restricted, repetitive, and stereotyped patterns of behavior, interests, and activities

• Delays or abnormal functioning in social interaction, language, or symbolic or imaginative play

The delays must be present prior to age three, and the diagnosis of Rett syndrome or Childhood Disintegrative Disorder must be ruled out.  Mental retardation is very common at one end of the spectrum that leans toward Autism, whereas is it not very common at the other end of the spectrum, where you will find Asperger's. There is limited development in self expression, in being receptive, and in the ability to express linguistically at the Autism end of the spectrum.

At the opposite end, those with Asperger's have adequate language abilities. PDD-NOS is the diagnosis when a child has symptoms of either Asperger's or Autism, but it does not meet the specific criteria for either.

Not too many years ago, clinicians did not have standardized testing instruments. However, within the last few years we have a much more standardized procedure for determining if someone has symptoms of PDD, and where on the spectrum the individual is.

It is helpful for you as a parent to be aware of the diagnostic and assessment process, so that you can ensure that your child is receiving the best care.

Diagnostic Process

It is usually the parent who first notices that something is not quite right with their baby. Sometimes the baby seems to give the parent a blank stare, and not really make eye contact, as if he or she is very distant. Also, the baby may not want to cuddle like other babies do. The baby may be unresponsive to the parents and/or seem to be focused intently on one item for long periods of time, oblivious to other people in the room.

Often, the parent notices a seemingly abrupt change in the baby, who had been babbling and cooing, then suddenly becomes silent, withdrawn, or indifferent to social overtures. Sometimes the baby becomes self abusive, displaying behaviors such as head banging.

This can be an especially worrisome and scary time for the parents. They may be wondering if they are doing something wrong, and of course, they are not.

The age of onset can be as early as infancy, but must occur before age three to receive the diagnosis of PDD. Sometimes, the parents can tell something is not right as early as birth, or shortly afterwards, because of the child's lack of interest in social interaction.

It is more difficult to identify in infancy, as the expressions of the disorder in infancy are more subtle and difficult to define than those seen after two years of age. There are a small number of cases where the child seemed to develop normally until the first or second year. However, this is only in a minority of cases.

Typical Symptoms

To receive a diagnosis of autism, the child must exhibit a total of six or more symptoms from three main categories as stated under the criteria Two of these symptoms must be from the category of qualitative impairment in social interaction, and must include marked impairment in the use of multiple nonverbal behaviors such as

• Eye-to-eye gaze

• Facial expression

• Body postures

• Gestures to regulate social interaction

• Failure to develop peer relationships appropriate to developmental level

• Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)

• Lack of social or emotional reciprocity

One of the six symptoms must include a communication impairment, such as

• 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) in individuals with adequate speech

• Marked impairment in the ability to initiate or sustain a

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  conversation with others

• Stereotyped and repetitive use of language or idiosyncratic language

• Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level, according to the American Psychiatric Association (2000).

Note that all children with an autistic spectrum disorder demonstrate deficits in

• Social interaction 

• Repetitive behaviors or interests 

• Verbal and nonverbal communication 

Autistic children often have unusual responses to sensory experiences, such as certain sounds, or the way objects look. Also keep in mind that the severity of each symptom will vary from child to child.

Assessment

The first step in assessment after the parents initially suspect their child of having PDD, will be in the form of screening. This includes the parents filling out questionnaires that will rule out other disorders, such as childhood disintegrative disorder, schizophrenia, and Rett syndrome.

Once it is determined that the child's symptoms seem to fit those of PDD, a full comprehensive diagnostic assessment will be conducted by a psychologist or psychiatrist, or it may be conducted by a multidisciplinary team that includes

• A psychologist 

• A neurologist 

• A psychiatrist 

• A speech therapist 

This assessment will likely include the use of specialized instruments that are designed to measure behaviors, including the Autism Diagnosis Interview-Revised (ADR-R) and the Autism Diagnostic Schedule (ADOS-G). I won't go into the specifics of these instruments.

However, note that if you bring your child in to see if he or she has autism, then you should be aware that you should be given this structured interview, and the child should be assessed with the ADOS. The ADOS is a set of tasks that the assessor gives the child to do, and then scored based on certain criteria after the child is observed performing the tasks. The resulting score will give an estimation of where the child is on the PDD spectrum. This should be congruent with the clinical interview and the diagnosis derived from the DSM IV.

In addition, lead screening will likely be done for a child who has remained in the oral-motor stage and continues to put objects into his or her mouth beyond the appropriate developmental age for this stage. This is very important, because you do not want to have the wrong diagnosis.

If your child does not have autism, but is exhibiting some of the serious symptoms, then it is imperative that you seek to find the correct diagnosis. Going to your doctor with this knowledge will increase the probability that you will get the right diagnosis and also find the correct intensive early intervention for your child.

Early Intervention Important

Early diagnosis and intervention is extremely important. Early intensive intervention can assist your child to acquire skills necessary to live a quality life, whereas without such intervention, a child with PDD can lose their ability to learn basic functional skills.

The following list of easily identifiable indicators can be found on a very good Internet video called Autism Among Us: Rising Concerns and the Public Health Response. If you suspect that your child might have PDD or you notice any of the following signs, do not hesitate to have him or her evaluated:

·          Does not babble, point, or make meaningful gestures by

          one year of age

·          Does not speak one word by 16 months

·          Does not combine two words by two years

·          Does not respond to his or her name

·          Loses language or social skills easily

·          Demonstrates poor eye contact

·          Does not seem to know how to play with toys

·          Excessively lines up toys or other objects

·          Is attached to one particular toy or object

·          Does not smile

·          At times seems to be a hearing-impaired child

Do not hesitate if you have any suspicions that your child is not developing appropriately. In future articles, we will explore early intervention, life after the diagnosis of PDD, and autism in adulthood.

Sources:

American Psychiatric Association. Diagnostic and

statistical manual of mental Disorders: DSM-IV-TR (fourth edition,

text revision). Washington DC: American Psychiatric Association,

2000.

Newschaffer CJ,  (Johns Hopkins Bloomberg School of Public

Health). Autism Among Us: Rising Concerns and the Public Health

Response [Video on the Internet]. Public Health Training Network,
   June 20, 2003. Available from: Public Health .

Dr. Maryam Bachmeier  has 11 years in the mental health field, and is currently a staff psychologist at the Napa State Hospital.