CHILDHOOD AUTISM

Dr Usha S Naik and Dr A Kanakalata Autism and the related pervasive developmental disorders (PDDs) are characterized by patterns of delay and deviance in the development of social, communicative, and cognitive skills, which arise in the first years of life. In the past few decades, our understanding of childhood Autism has changed considerably. A) PREVALENCE The Centers for Disease Control (CDC) has documented that more children are being diagnosed with an ASD than ever before. A conservative estimate is of 1/500 children but some regions like California report a a prevalence of 1/88 children .The risk is 3-4 times higher in males than females.. B) ETIOLOGY Whereas in the past the focus was on a search for a chromosomal cause, chromosomal microarray analysis (CMA) has identified copy number variants in as many as 8 % of children . The interplay of several genes is now considered as etiologically important. Epigenetics is being given greater recognition as in all branches of medicine . C) ASSESSMENTS The evaluating checklist has been lengthened considerably. However a form based on DM IV will be useful as it will serve as diagnostic tool as well as a history taking one. DSM V will come into effect later in 2013 . Regression in previously acquired skills is being increasingly observed . Most children who regress do so between 12-18 months. D) TREATMENT The goals of treatment are two fold : to reduce disruptive behaviour and to increase communication and learning .Treatment will depend on the age at the time of referral. The different treatment options can be bewildering. Children need to receive a combination of Psycho educational approaches and Medical Interventions.

Early Intervention with children with Autism

When a child is younger, the brain has much more plasticity or ability to change and so changing or teaching new behaviour is much easier. Earlier studies showed that only half of all children with autism would gain speaking abilities. Recent studies however, indicate that as many as 80 percent of children with autism can learn to talk. Recognising and diagnosing autism before pre-school age has been uncommon until the last few years. It has however now been shown that a diagnosis can be valid and reliable at 2 years of age. In future it is likely that autism will be diagnosed for most children in the toddler age period (18 - 30 months). Very early therapeutic intervention is likely to improve developmental and adaptive outcomes .The quality of intervention is as important as quantity. Intervention should start as soon as characteristics of ASD are noted and continue for as long as required. When intervention starts early ,children experience success and are more likely to be engage socially and learn language and communication skills. Children are also less likely to become frustrated with a consequent decrease in challenging behaviours . Effective EI programs for children should provide an autism specific curriculum content focusing on attention, compliance, imitation, language, and social skills in a highly structured and supportive teaching environment with opportunities to generalize skills. Family support is essential . The best interventions are the most intensive and focused. The best known behavioural programme is ABA ( Applied Behaviour Analysis) which uses one on one interaction between the adult and the child . Excellent outcomes have been reported where children may

be indistinguishable from normal. However the method needs more than 24 hours a week of treatment, requires highly trained and motivated therapists and is expensive. Another method is TEACCH which is a 'whole life' approach aimed at supporting children, adolescents, and adults with autism through the provision of visual information, structure, and predictability. Goals are individualised and based on a comprehensive assessment at the start of the program . Each child's strengths and interests are identified and used as the basis for supporting the development of other functional, and even vocational, skills . Attention is paid to the development of communication skills and the use of multimodal communication is encouraged. FAMILY SUPPORT Family support is essential and can help relieve the tremendous stress faced by parents of children with Autism. Parent groups serve this purpose. Breaking the news can be a difficult procedure as many parents have heard of autism and cannot believe it is happening to them. Parents have a great need to know more about this problem and nothing can substitute for time spent with the family. MEDICATION Medication should be used in the smallest dose for the shortest period of time keeping the side effects in mind . In, 2006 risperidone was approved for the symptomatic treatment of irritability in autistic children and adolescents aged 5 to 16 .The behaviours include aggression, deliberate selfinjury and temper tantrums. Other problems like anxiety, depression ,aggression and obsessive compulsive behaviour may need medication .Fluoxetine and sertraline are approved for children age 7 and older .Propranolol in small doses can relieve anxiety . Associated seizures are a definite indication for medication .These include such medications as carbamazepine lamotrigine topiramate, and valproic acid. SPECIFIC THERAPIES Many specific therapies are reportedly successful in Autism. These include Speech therapy cognitive behaviour therapy and sensory integration. Many of these therapies can only be focused on once the child becomes responsive. Many non established treatments abound and parent should be cautioned against those likely to be dangerous. Dietary Therapy and the use of Supplements Recent reports support a trial of elimination diets like the gluten-free, casein-free diet. Vitamin and mineral supplements are required to prevent deficiencies .Supplements that have proven useful include omega 3 fatty acids and N acetlyl cysteine, vitamin B6, and magnesium supplements . The result of research studies is mixed : some children respond very positively, some negatively, some not at all or very little . E) PROGNOSIS Regular follow up is required. Parents often shop for treatment so ideally all services can be offered in one setting but this has been mostly difficult to achieve. With early and appropriate intervention, long term out comes have improved and some children grow into self sufficiency in adulthood while several are able to function with support. The improvement in several children can be so remarkable that we need to adopt a more optimistic attitude. However caution is needed in children with evidence of motor delay .