INTRODUCTION:

Autism spectrum disorders (ASDs) are complex neurodevelopmental conditions that involve impairments in social interaction, communication and behavioral functioning such as repetitive and stereotyped behaviors. While individuals with ASDs are characterized by a core set of symptoms, there is wide heterogeneity in the severity of the disorder. Three subtypes are typically used to classify ASDs that include autistic disorder, Asperger's disorder and pervasive developmental disorder – not otherwise specified (PDD-NOS). Diagnosis of ASD subtypes requires a full understanding of a child's profile of abilities including developmental/ cognitive, speech, language, communication, social, adaptive, sensorimotor and behaviors. Owing to the wide range of abilities and limitations across clinical characteristic, clinicians may not reliably agree on the diagnostic subtypes of ASD – that is, clinicians may apply the specific diagnostic labels(autistic disorder, Asperger's disorder and PDD- NOS) differently across sites even when standardized clinical instruments are used. Children who meet full diagnostic criteria for ASD are likely to be categorized as autistic disorder or classic autism, which typically is the most severe form.²

What is ASD

ASD is a complex neurological and developmental disorder that begins early in life and affects how a person acts and interacts with others, communicates, and learns. ASD affects the structure and function of the brain and nervous system. Because it affects development, ASD is called a developmental disorder. ASD can last throughout a person's life.

People with this disorder have problems with.²

· Communication and interaction with other people

· Restricted interests and repetitive behaviours.

Causes of autism spectrum disorder

The exact causes of autism spectrum disorder (ASD) are unknown, although it is thought that several complex genetic and environmental factors are involved.³

The causes of ASD can be described in two ways:

· Primary ASD (also known as idiopathic ASD) – where no underlying factors can be identified to explain why ASD has developed.

· Secondary ASD – where an underlying medical condition or environmental factor thought to increase the risk of ASD is identified.

About 90% of cases of ASD are primary, and about 10% are secondary.

Risk factors

· Genetic factors – certain genetic mutations may make a child more likely to develop ASD.

· Environmental factors – during pregnancy, a child may be exposed to certain environmental factors that could increase the risk of developing ASD.

· Psychological factors – people with ASD may think in certain ways that contribute towards their symptoms.

· Neurological factors – specific problems with the development of the brain and nervous system could contribute to the symptoms of ASD.

· Other health conditions – certain health conditions associated with higher rates of ASD. It includes Fragile X syndrome, Tuberous sclerosis, Rett syndrome, Neurofibromatosis, Muscular dystrophy, Down’s syndrome, Cerebral palsy, Intellectual disability.³

Types of autism spectrum disorders

The autism spectrum disorders belong to an “umbrella” category of five childhood-onset conditions known as pervasive developmental disorders (PDD). Some autism specialists use the terms pervasive developmental disorder and autism spectrum disorder interchangeably. However, when most people talk about the autism spectrum disorders, they are referring to The three most common PDDs:³

Autism

Asperger's Syndrome

Pervasive Developmental Disorder - Not Otherwise Specified (PDD-NOS)

Childhood disintegrative disorder and Rett Syndrome are the other pervasive developmental disorders. Because both are extremely rare genetic diseases, they are usually considered to be separate medical conditions that don't truly belong on the autism spectrum.⁴

Signs and Symptoms of Autism Spectrum Disorder

The signs and symptoms of the autism spectrum disorders include problems with social skills, speech and language, and restricted activities and interests.⁴

1. Social Skills

Basic social interaction can be difficult for children with autism spectrum disorders. Symptoms may include:

· Unusual or inappropriate body language, gestures, and facial expressions (e.g. avoiding eye contact or using facial expressions that don’t match what he or she is saying)

· Lack of interest in other people or in sharing interests or achievements (e.g. showing you a drawing, pointing to a bird)

· Unlikely to approach others or to pursue social interaction; comes across as aloof and detached; prefers to be alone

· Difficulty understanding other people’s feelings, reactions, and nonverbal cues

· Resistance to being touched

· Difficulty or failure to make friends with children the same age.

2. Speech and Language

Problems with speech and language comprehension are signs of the autism spectrum disorders. Symptoms may include:

· Delay in learning how to speak (after the age of two) or doesn’t talk at all

· Speaking in an abnormal tone of voice, or with an odd rhythm or pitch

· Repeating words or phrases over and over without communicative intent

· Trouble starting a conversation or keeping it going

· Difficulty communicating needs or desires

· Doesn’t understand simple statements or questions.

3. Restricted Behaviour and play

Children with autism spectrum disorders are often restricted, rigid, and even obsessive in their behaviors, activities, and interests. Symptoms may include:

· Repetitive body movements (hand flapping, rocking, spinning); moving constantly

· Obsessive attachment to unusual objects (rubber bands, keys, light switches)

· Preoccupation with a specific topic of interest, often involving numbers or symbols (maps, license plates, sports statistics)

· A strong need for sameness, order, and routines (e.g. lines up toys, follows a rigid schedule). Gets upset by change in their routine or environment.

· Clumsiness, abnormal posture, or odd ways of moving

· Fascinated by spinning objects, moving pieces, or parts of toys (e.g. spinning the wheels on a race car, instead of playing with the whole car).

Types of ASD screening instruments

Examples of screening instruments for toddlers and pre-schoolers include⁵:

· Checklist of Autism in Toddlers (CHAT)

· Modified Checklist for Autism in Toddlers (M-CHAT)

· Screening Tool for Autism in Two-Year-Olds (STAT)

· Social Communication Questionnaire (SCQ)

· Communication and Symbolic Behavior Scales (CSBS).

To screen for mild ASD or Asperger syndrome in older children, the doctor may rely on different screening instruments, such as:

· Autism Spectrum Screening Questionnaire (ASSQ)

· Australian Scale for Asperger's Syndrome (ASAS)

· Childhood Asperger Syndrome Test (CAST).

Management
A multidisciplinary team of professionals trained and specialized in autism is necessary.The team should include a developmental pediatrician, a child psychiatrist, an occupational (behavioral) therapist, a speech therapist, a psychologist, a specialist teacher and a social worker.⁶

- Initial assessment

A child meeting the criteria for autism should undergo a thorough medical examination.

This involves a detailed medical and developmental history, meticulous physical examination to identify neurocutaneous markers for tuberous sclerosis (including Wood's light examination) and dysmorphic features for fragile X syndrome (do chromosome study if indicated).Complete blood count and peripheral blood smear examination should be done to rule out iron deficiency anemia if the child's dietary habits are limited.⁶

Routine Cranial CT / MRI scan are not necessary for diagnosing autism. However; audiometric and ophthalmic examinations should be done to rule out associated hearing and visual deficits, as this is essential in any communication disorder. There is no need to do an electroencephalography routinely but a high index of clinical suspicion should be maintained for subtle symptoms of seizures.

Early intensive behavioral and educational intervention therapy

There is currently no known 'cure' for autism. The only treatment that has been shown to make a positive impact in ameliorating the core behavioral deficits in autistic children is early intensive behavioral and educational intervention therapy.

Judicious use of psychotropic medications

Autism in itself is not an indication for using psychotropic medications as drugs cannot be a substitute for behavioral and educational interventions. These medications are used to reduce (but not necessarily eliminate) interfering behaviors to make the child more amenable to interventions. Although still an emerging field, benefit has been reported with:

(i) a typical antipsychotics (risperidone, olanzapine, clozapine) for temper tantrums, aggression, or self-injurious behavior;

(ii) selective serotonin-reuptake inhibitors (sertraline, citalopram, fluoxetine) for anxiety and repetitive behaviors; and

(iii) psychostimulant (methylphenidate), opioid antagonist (naltrexone) for hyperactivityThe risk of drug toxicity must always be balanced against the benefits of reducing interfering behaviors

Management of Associated Epilepsy

Symptomatic epilepsy needs to be treated and appropriate medication is prescribed depending on the seizure type. However, care should be taken to avoid antiepileptic drugs such as phenobarbitone and phenytoin which are known to cause hyperactivity and impair cognition.⁷

CONCLUSION

Autism spectrum disorder (ASD) is a neurological and developmental disorder that begins early in childhood and lasts throughout a person's life. It affects how a person acts and interacts with others, communicates, and learns. It includes what used to be known as Asperger syndrome and pervasive developmental disorders.

It is called a "spectrum" disorder because people with ASD can have a range of symptoms. People with ASD might have problems talking with you, or they might not look you in the eye when you talk to them. They may also have restricted interests and repetitive behaviors. They may spend a lot of time putting things in order, or they may say the same sentence again and again. They may often seem to be in their "own world."⁸

At well-child checkups, the health care provider should check your child's development. If there are signs of ASD, your child will have a comprehensive evaluation. It may include a team of specialists, doing various tests and evaluations to make a diagnosis.

REFERENCES:

1. Nadeem Kirmani, Behavioural and Parental Intervention in Autism: A case Report. International journal of psychology and psychiatric , 3(2)Pg : 77-91,0ct 2015.

2. P. Chitra. Predisposing factors among children with autism: International Journal of Nursing Education; 7(3) Pg 178-182, jul 2015.

3. Strömland K, Nordin V, Miller M, Akerström B, Gillberg C. Autism in thalidomide embryopathy: a population study. Dev Med Child Neurol. 1994; 36(4): 351-356.

4. Gardener H, Spiegelman D, Buka SL. Perinatal and neonatal risk factors for autism: a comprehensive meta-analysis. Pediatrics. 2011; 128(2): 344-355..

5. Vijay Sagar KJ. Associate professor, Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurological Sciences (NIMHANS), Bangalore. Karnataka. India. Indian journal of psychiatry.

6. Lokhandwala, T., Khanna, R., and West-Strum, D. (2012). Hospitalization burden among individuals with autism. Journal of Autism Developmental Disorders, 42(1), 95-104

7. Johnson, N.L., Lashley, J., Stonek, A.V., and Bonjour, A. (2012). Children with developmental disabilities at a pediatric hospital: Staff education to prevent and manage challenging behaviors. Journal of Pediatric Nursing, 27(2), 742-749.

8. Handle with Care: Top Ten Tips a Nurse Should Know Before Caring For a Hospitalized Child with Autism Spectrum Disorder Adriane A. Jolly Pediatric Nursing/January-February 2015; Vol. 41: No. 1

Received on 01.01.2016 Modified on 21.02.2016

Int. J. Nur. Edu. and Research. 2016; 4(2): 223-226.

DOI: 10.5958/2454-2660.2016.00044.2