Delayed milestones: Autism a possible cause in children

Introduction

Every child is special. We can’t compare one with another. Most of the times parents are apprehensive about the delayed milestones in children, but there is one thing that is noteworthy that delayed milestones not always mean that there is some underlying disorder. For every milestone to be achieved there is a time period, if a milestone is not achieved till completion of that period of time than you should consult your healthcare provider to know the cause of delayed development.

What is autism?

Autism is a complex neurobehavioral disorder that includes impairment in social interaction and developmental language and communication skill combined with rigid, repetitive behaviour. But being a parent you will surely notice that your child is special in a unique sense. It is one thing that has been said by most of the parents and can only be observed by you. Autism spectrum disorder is a disorder that usually manifests itself in first three years of life. It is characterised by:

  1. Inability in getting along with people or poor social behaviour
  2. Abnormal repetitive speech
  3. Difficult to express themselves either with words or through gesture, facial expression and touch
  4. Poor personal bonding
  5. Compulsive repetitive behaviour and activities

One of the most well-known of these disorders is Autism and Asperger’s syndrome.

Asperger’s syndrome

It is different from classic autism in:

  1. Language is usually intact as compared to classical autism.
  2. Contrasting to classical autism features typically appear later in childhood
  3. Patients show a particularly high intelligence quotient (IQ).
Pervasive development disorder

Pervasive developmental disorder also known as PDD is the most generalized form of autistic disorder. Children who have autistic behaviours but don’t have any other associated disorder can be said to have generalized pervasive development disorder.

Rett Syndrome

Rett syndrome is one of the neurobehavioral disorders that is more common in girls. Children with Rett syndrome develop normally approximately till age of 1-4 years. Earlier it is a random repetitive movement of hands that in later life is replaced by purposeful repetitive movement of hands.

Autism is three to four times more common in boys than girls.

What are the signs and symptoms?

Usually children with autism spectrum disorder (ASD) have a difficulty interacting with society and forming emotional bonds with friends and family. Usually such children don’t have many friends. Some people affected with ASD are exceptionally intelligent and creative while approximately 70% of the affected individuals have an IQ below 70.

The impact of this development disorder is manifold and can be seen in many areas of person’s life. Its effect ranges from social relationships to communication problems and behaviour problems. Let’s have a look over it one by one.

Social Interaction and Reciprocity
  1. Exhibit impairments in initiating social interactions and in interpersonal relatedness.
  2. Show deficits in using gaze and facial expression to communicate and in joint attention (drawing another person's attention to a distant object).
  3. Avoid eye contact
  4. Appear deaf
  5. Remain aloof and withdrawn socially
  6. Some show a desire to engage socially but have difficulties grasping social codes.

The degree and type of the social deficits vary among individuals, and they are affected by developmental level and change over time.

Language and Communication

Most children with ASD have delays in reaching speech milestones, which is the main reason for their referral for an evaluation.

  1. Start developing language, then abruptly stop talking altogether
  2. Semantic-pragmatic language deficit, meaning the use of language for communication purposes is particularly impaired.
  3. Immediate echolalia (repeating what have been just heard)
  4. Delayed echolalia (verbalizing fragments of language or citation heard in the past)
  5. Delay or absence of imitation, imaginative, and pretend play are common.
  6. Individuals with Asperger syndrome have higher IQs and mild or no early speech delay. Their language can become functional and even sophisticated (using “big words”).

Restricted, Repetitive, and Stereotypic Behaviour and Interests

Behaviour tends to be preservative and repetitious and tends to reflect the desire for sameness and rigid routines. It includes:

  1. Stereotypic motor and verbal behaviour (flapping hands, finger mannerisms)
  2. Tendency to be preoccupied with limited objects, activities or circumscribed interests (traffic lights, flushing toilets).
  3. Interest in parts of objects and stereotypic behaviour (turning wheels, doll's eyes, lining up objects in identical patterns)
  4. Rigid adherence to routines, compulsions and rituals
  5. Have an obsession for maintaining an unchanging environment and rigidly following familiar patterns in their everyday routines. Many insist on eating the same foods, at the same time, sitting at precisely the same place at the table every day. They may get furious or wildly upset even with a minor change in their routine.
Note:

They show no sensitivity to burns or bruises, and may engage in self-mutilation, such as eye gouging. On the other hand, some are painfully sensitive to sound, touch, sight or smell. Some display a combination of lack of response to stimuli, including pain, with abnormal fearlessness. Some cover their ears and scream at the sound of a vacuum cleaner, a distant aircraft, a telephone ringing or even the wind.

Oral Manifestations

  1. People with autism may prefer sweet foods, sometimes given as rewards, and may have poor oral hygiene (these factors may increase risk of dental caries and periodontal disease)
  2. They may have signs of bruxism (clenching of their teeth)
  3. More than 20% of children with autism bite objects or introduce their fingers in the mouth routinely, resulting in traumatic lesions
  4. Oral lesions may also be present due to auto-aggression or convulsive crisis.

How is it diagnosed?

Diagnosis of autism requires a thorough caregiver interview and an interactive assessment of the child. Two gold standard instruments based on DSM-V criteria for autism are currently widely used to obtain reliable and valid diagnosis of autism:

  1. The Autism Diagnostic Interview—Revised (ADI-R)
  2. The Autism Diagnostic Observation Schedule (ADOS).

Diagnosis of autism is established by clinical findings, but it may remain undiagnosed until the age of 4 or 5 years.

Management

Management of autism requires a multimodal approach that typically involves special education, behavioural interventions, and pharmacologic treatment of problematic behaviours and co-morbidities. Intervention focuses on improving social and language skills and reduction of maladaptive behaviours. The goals are to improve the child's overall functional and adaptive status and provide support for the family.

Behavioural teaching approaches

Dealing with an autistic child needs a lot of patience and love. But to cope with the surroundings, environment and the society behaviour teaching approaches are very essential and needful as well. Some of the approaches are explained as under:

Applied Behaviour Analysis (ABA)

Applied behaviour analysis (ABA) employs methods based on scientific principles of behaviour aimed at building socially useful repertoires and reducing behaviour problems. ABA focuses on teaching small measurable units of behaviour using discrete trial treatment (DTT) in mass trials for 30 to 40 hours a week for at least 2 years in home-based or centre-based programs. Simple responses are then built systematically into complex age-appropriate skills with emphasis on teaching how to learn from the normal environment. For more advanced children, ABA is implemented in relatively unstructured situations to enhance generalization, increase motivation, and develop social skills. Common behavioural instructional strategies include-

  1. Incidental teaching (child-initiated natural interactions)
  2. Pivotal responses training (certain behaviours are seen as central for development)
  3. Peer mediated teaching (children with autism are instructed by their peers).

Follow-up studies have showed that approximately half of the children receiving behavioural treatment make substantial gains in the targeted areas and on standardized tests.

Treatment and Education of Autistic and Related Communication-Handicapped Children (TEACCH)

Originally a statewide project in North Carolina, it is one of the best-known approaches. It focuses on the use of visual cues, schedules, and work stations to teach individuals with ASD. The program emphasizes improving communication and adaptation to environment skills. The structure of the environment is important in TEACCH because it may increase the likelihood that individuals with autism will be able to understand and predict their surroundings and the expectations for their behaviour.

Developmental approaches

Developmental approaches involve approximately 20 hours per week of centre-based developmental intervention and emphasize on playing, language, cognition, and social relationships. This approach results in gains in cognition and language.

Communication

Speech and language intervention is important and should be provided by personnel with experience in autism. The picture exchange communication system (PECS) is widely used in nonverbal children. The system consists of numerous picture symbols printed on small cards that the child can give to someone to communicate. The exchange portion of the program teaches the children that giving someone something (pictures and, later, words) results in receiving something back (the item they want).

Sensory Integration

Sensory integration (SI) therapy focuses on combining tactile, vestibular, and proprioceptive input to increase attention and arousal. It is based on the theory that disturbances in sensory modulation are the primary problem in autism and therefore may result in improved communication and social relation.

Medical management

There is only limited evidence that drug treatments for autism are effective. However, specific class of drugs are prescribed to control the signs and symptoms and also for the comorbidities associated with this disease (e.g. Attention Deficit Hyperactivity Disorder ADHD, Seizures, Sleep problems, Anxiety, etc)

  1. Anxiolytics and antidepressants for anxiety and depression
  2. Atypical neuroleptics for disruptive and aggressive behaviour
  3. Selective serotonin reuptake inhibitor (SSRI) for mood problems
  4. Beta-blockers and alpha-adrenergic agonists
  5. Anticonvulsants if seizures present
  6. Stimulants for hyperactivity and attention disorders

Caution

  1. In general, poly pharmacy is not recommended. It is difficult to assess which medicine works, there is more potential for side effects and drug interactions, and some combinations simply do not work and might be risky altogether.
  2. Parents should be cautioned about the possibility of misinformation regarding etiology (e.g. the alleged association with measles, mumps and rubella [MMR] vaccines) and miracle cures (secretin, vitamins, diets, etc.).

The care of a child with autism can sometimes be confusing for parents because it requires the involvement of multiple disciplines, from educators and developmental therapists (speech, motor, behaviour) to developmental and behavioural paediatricians, child psychiatrists, and child neurologists. Therefore, it is advisable to include parents in the training programs for their child. It can increase parents' feeling of relatedness with their child and improve their sense of competence as parents, thereby decreasing emotional stress. A regional centre for diagnosis and treatment of autism can greatly assist parents in navigating all these resources. Early diagnosis resulting in early appropriate and intensive intervention improves the long-term outcome of ASD.

All parents should remember this - AUTISM – Always Unique Totally Interesting Sometimes Mysterious.

Every child with autism is special and should be showered upon with all the love, care and acceptance that he/she deserves.

Other possible causes for attention deficit

It is essential to rule out other disorders which can resemble autism, such as

  1. Hearing loss
  2. Speech problems
  3. Learning disability
  4. Neurological problems

References


  1. Current Pediatric Therapy, Eighteenth Edition. Fredric D. Burg, Julie R. Ingelfinger, Richard A. Polin, Anne A. Gershon.Elsevier Inc. ISBN-13: 978-0-7216-0549-4.
  2. Current Diagnosis & Treatment: Paediatrics, Nineteenth Edition. William W. Hay, Jr.,Myron J. Levin, Judith M. Sondheimer,Robin R. Deterding. The McGraw-Hill Companies, Inc. ISBN 978-0-07-154433-7.
  3. Textbook of Pedodontics, Second Edition. Shobha Tandon, Paras Medical Publisher, ISBN 978-81-8191-241-1.
  4. Dentistry for the Child and Adolescent, Ninth Edition. Jeffrey A. Dean, David R. Avery, Ralph E. McDonald. Elsevier Inc. ISBN 978-0-323-05724-0
  5. Handbook of Paediatric Dentistry, Third Edition. Angus C. Cameron, Richard P. Widmer. Mosby Elsevier Limited, ISBN 978 0 7234 3452 8.

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Dr. Sanjay Soni

MDS (Oral and Maxillofacial Surgery) | Reader (MN DAV Dental College and Hospital)

MN DAV Dental College, Solan

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