Frequently Asked Questions: Autism

What is Autism?

Autism Spectrum Disorder, or autism, is a developmental disorder that is diagnosed when a child demonstrates problems or abnormalities in language, socialization, and behavior. For example, autistic children typically have significant speech delays; they may be nonverbal or only babble, exhibit a limited vocabulary, or use words or phrases in a highly repetitive and obsessive fashion (example: use the same word or phrase repeatedly).

Socialization is a common problem with autistic children. Being withdrawn and “in their world" is exceedingly common. Sometimes, kids with ASD try to interact but don't know how to act or what to say, which leads to social withdrawal.

Unusual mannerisms, sometimes referred to as ‘self-stimulatory behaviors’ or 'stims,' can also be very common. These can include toe-walking (that continues past 18 months of age), hand-flapping, staring for extended periods, jumping, and obsessively clinging to a particular toy, among many other unusual behaviors. We refer to these odd behaviors as self-stimulatory because they seem to mentally stimulate the child and reinforce the activity. Understandably, these behaviors tend to interfere with normal socialization.

Not uncommonly, there are also hyper or hyposensitivities (for example, being extra sensitive to particular fabrics or insensitive to pain), sleep difficulties (not sleeping throughout the night), food-related issues (being exceptionally finicky or having difficulties with portion management, i.e., putting too much food in their mouth at one time), and difficulties tolerating changes in routine.

When do symptoms begin to surface?

The behaviors and delays described above begin to surface before the second or third birthday, and sometimes before the first birthday. There are times when the child may develop “normally” for the first 18 months or so, then regress in the form of losing words, socially withdrawing, and displaying those aforementioned odd behaviors.

Are all autistic children about the same? What does "spectrum disorder" mean?

Autistic children are quite different from one another, just as all children are unique. Moreover, children with autism can present quite differently in the severity and extent of symptoms. For that reason, Autistic Disorder is often referred to as a “spectrum” disorder. This means that the signs and symptoms are on a “spectrum” or “continuum” from one extreme to the other.

For example, one “autistic” child may be able to speak in short phrases, demonstrate affection with his parents, and only occasionally hand-flap. However, another child, also diagnosed with autism, may be completely nonverbal, exhibit no affection, and display incessant odd behaviors, including toe-walking, spinning objects, and obsessively lining up objects.

The “spectrum” can also refer to the wider scope of diagnoses, including Autism, Pervasive Developmental Disorder Not Otherwise Specified (PDDNOS), and Asperger’s disorder. The two extremes on this spectrum consist of Autistic Disorder at one end of the spectrum, being quite debilitating, with Asperger’s Disorder at the other end.

Asperger’s Disorder will be described later, which consists of several autistic-like signs, including severe socialization deficits, a tendency to obsess on topics, and an odd use of language. However, most people with Asperger’s Disorder communicate verbally without too much problem and generally desire to be social; they just aren’t sure how.

What are the “Levels” of Autism, and what do the levels mean?

There are levels of autism that reflect how much support a child with autism will need to get through his day. The levels range from ‘1’—not much support—to ‘3’—lots of support. Below is a more detailed breakdown:

Level 1: Basic Support

Level 1 describes a child diagnosed with autism who requires minimal support to complete daily tasks. People with level 1 ASD (Autism Spectrum Disorder) may have a difficult time with social nuances and may be rigid in their thinking but are fully verbal and able to carry out many activities of daily living with a large degree of independence.

Level 2: Substantial Support

Children diagnosed with ASD level 2 have a harder time than those diagnosed with level 1 and may find it challenging to communicate or socialize in ways that are accepted or understood by neurotypical society. They will find it harder to change focus or shift from one activity to the next. Consequently, they tend to need quite a bit of support to get through daily routines, and 1:1 support is occasionally necessary.

Level 3: Intensive Support

Children diagnosed with ASD level 3 need the most support and guidance to complete daily tasks. People in this category will have many of the same traits as those with level 1 and 2 diagnoses, but the severity level is more substantial and debilitating, leading to significant challenges in communication, social interaction, and adaptive functioning. Children at this level will often need 1:1 support to navigate through a daily schedule.

What Is High-Functioning Autism, or Asperger’s Disorder?

Asperger’s Disorder was coined by Hans Asperger in 1944. He described individuals who present with a similar pattern of unusual behavior, such as being fully fluent and of average intelligence but often using language in an odd and peculiar manner and displaying a mechanical quality in the flow of their speech.

The ‘Asperger’s’ diagnosis is no longer used on a clinical basis, but the term remains relevant and continues to be used to help differentiate those more mildly on the spectrum from more severe cases of autism. The current nomenclature is Autism Spectrum Disorder, level 1. Moreover, High Functioning Autism (HFA) also is not a clinical term but simply descriptive of those with more mild symptoms.

In any case, individuals with HFA/Asperger’s disorder (i.e., ASD, Level 1) tend to be rather obsessive about various topics of interest and will speak on these topics, and sometimes nothing else, for days or weeks before moving on to some other topic. However, the hallmark and most predominant feature is poor socialization skills. These individuals tend to have poor eye contact, disturbed personal boundaries (can be too intrusive in how close they stand to someone), interrupt, struggle to understand how to begin or end a conversation, and have difficulty with changes in routine.

Individuals with HFA/Asperger’s Disorder do not have trouble with speech fluency and are generally lacking in those self-stimulatory behaviors, compared to a child, teen, or young adult with autism who has difficulty with both areas.

How do I know if my child has Autism Spectrum Disorder or Asperger’s?

Clues typically begin to surface early on, between one and three years of age. Commonly, a parent or pediatrician expresses concerns about the child’s lack of language development and related abnormalities. The pediatrician may then refer the parents to a facility that specializes in the evaluation and treatment of autism spectrum disorders, such as The Autism Centers of Pittsburgh (ACP) or Community Psychiatric Centers (CPC), for a comprehensive evaluation. At CPC, the child is evaluated by either Dr. Lowenstein, M.D., who is a board-certified child psychiatrist, or Dr. Carosso, Psy.D., who is a licensed psychologist and a certified school psychologist.

Both have decades of experience assessing and treating developmentally delayed children. The evaluation includes a complete history and assessment of current functioning, including the child’s social engagement, play skills, speech and language capacity, eye contact, and assessment of any “self-stimulatory behaviors," among many other targeted areas. The assessment at CPC will culminate in the explanation of the diagnosis, treatment considerations, ample time to answer questions, and a comprehensive written report with abundant recommendations and resources.

Can other conditions, such as Attention Deficit Disorder (ADD/ADHD), co-occur alongside Autism?

Yes, psychiatric conditions often co-occur. For example, a child with autism may also display overactivity, inattention, heightened impulsivity, and oppositional/defiant behaviors. A comprehensive treatment plan is necessary to target developmental delays and abnormalities, but also these additional behavioral issues.

Depression is common, particularly in older children with high-functioning autism (Autism Spectrum Disorder, Level 1) given the tendency to experience rejection by peers. As will be discussed below, counseling and, at times, medication management can also be beneficial for addressing both the developmental delays and the associated behavioral issues, including depression.

Why are speech delays common with many children with Autism Spectrum Disorder?

While it is not a diagnostic factor for autism, delayed speech development can be a common, early indicator of Autism Spectrum Disorder.

It’s not clear why speech delays are common in children on the autism spectrum. However, it is suspected that multiple factors may be involved. Differences in brain function and development in children with ASD are one consideration. Difficulties with socialization is another likely factor, as language skills develop primarily through social interactions.

Sensory processing difficulties may also play a role. Some children with ASD have difficulty processing multiple stimuli at once. For instance, what they see in a social situation may be difficult for them to synchronize with what they hear, contributing to impaired language development.

What are the treatment options for these disorders?

After a comprehensive assessment is completed and an accurate diagnosis is provided and explained, it is time to focus on treatment.

There are many options for a child, teen, or young adult on the autism spectrum, but most treatment strategies are based on Applied Behavioral Analysis, which involves analyzing the small steps needed to complete any given task and identifying potential reinforcers (those things that help increase the chance that the preferred behavior will occur) among many other considerations.

The information gathered is used to develop “discrete trial programs” to help the child learn the individual steps toward task completion, such as identifying the name of an object to work toward the goal of asking for the object. In this way, the child learns the sub-steps for completing each activity through repeated trials, which leads to learning the entire task. This strategy is also applied to teaching language in a strategy referred to as “Verbal Behavior," which was coined by B.F. In 1938, B.F. Skinner introduced this strategy in his classic book The Behavior of Organisms.

Other treatments include Relationship Development Therapy, the TEACCH program, and Greenspan methods, all of which use various strategies and floor play to facilitate social skill development, particularly for children with high-functioning autism. Research results, particularly discrete trial regimens, generally support these treatment strategies.

There are also various food and supplement-related interventions, including, for example, eliminating gluten and casein (dairy and wheat products) from the diet, with some parents reporting subsequent positive results but, overall, the research results being inconclusive.

Various social-skill development programs can be used for children with high-functioning autism. Self-stimulatory behavior is redirected into more appropriate behavior, such as directing a child who rocks to use a rocking chair. Sleep and food-related difficulties are also targeted with behavioral approaches and, if necessary, referral for a psychiatric consult and to a local feeding clinic.

The clinicians at Autism Centers of Pittsburgh use a wide variety of treatment options tailored to each child’s strengths while targeting his or her weaknesses. ACP clinicians are trained in all treatment modalities to meet the needs of any child diagnosed with autism.

What about medication? Can this type of therapy be helpful?

No medication has been found to cure autism. However, studies have shown that various medications may help children benefit from educational and other behavioral interventions and can reduce some of the target behaviors associated with autism. Medications can also treat the so-called “co-morbid” conditions often found in children with autism, such as ADHD, Tourette’s Disorder, Depression, and OCD.

Major tranquilizers, or 'neuroleptics,' such as Haldol, Risperdal, Zyprexa, Seroquel, and Abilify, have been found to reduce levels of withdrawal, stereotypic movements, aggression, and self-abuse. Stimulant medications such as Adderall, Concerta, Metadate, Ritalin, Focalin, and Methylin have been found to reduce levels of overactivity, poor concentration, distractibility, and impulsiveness. Tic-like and obsessive-compulsive behaviors, as well as some forms of self-injury, have been successfully treated with medications such as Tenex, Clonidine, Prozac, Luvox, and Anafranil. Antidepressants and mood stabilizers, which are types of medications used to treat mood disorders, like Lithium and Depakote, have been reported to reduce some signs of depression and mood instability. Beta-blocker-type medications, such as Inderal, usually indicated in the treatment of hypertension, have been found to reduce aggression.

Evaluations of children for Autism should include a medical history and physical examination and neurological testing, as well as vision and hearing testing to rule out the presence of inherited disorders such as Fragile X syndrome or tuberous sclerosis, hearing loss, and seizure disorders associated with Autism. A DNA test for Fragile X syndrome is available, as are other genetic screening and chromosomal analytic tests to rule out inherited metabolic disorders.

What is the long-term outlook for children with Autism, or an Autistic Spectrum Disorder?

The outcome is difficult to predict. Many children demonstrate remarkable progress such that, for example, in only a few years, a child may be barely distinguishable from his or her peers. However, other children continue to demonstrate significant symptoms. Nevertheless, virtually all children provided intensive treatment display progress that may manifest, for example, in improved eye contact, being able to carry on a conversation for two exchanges rather than only one, or being able to express four-word rather than two-word expressions. Improvements may seem small, but in terms of being able to function at a higher level in school and the community and ongoing improvements over time, these small changes can add up to substantial advances. Consequently, the need for intensive and long-term treatment is vital.