Sandra Laujin

What is autism?

Autism is considered to be a neurodevelopmental disorder - a developmental disorder in childhood that has a neurobiological origin.

Autism is an early onset disorder in the development of the child: the symptoms manifest in the early stages of childhood, before the age of 3.

Autism is characterised predominantly by severe difficulties in social interaction. A persistent deficit in communication and social interactions, along with a restricted and repetitive pattern of behaviour, interests or activities, are generally observed.

The signs and symptoms of autism are very variable from one child to another and for the same child at different points in time. There are as many forms of autism as there are people affected. It seems everyone has their own unique symptoms. For example, some children with autism have speech difficulties and others don’t.

Actually, the particularity of this disorder is that it is not determined by one difficulty in particular, but by several, all related in some way to social interactions, empathy, communication and behavioural flexibility.

Health Professionals have therefore attempted to define 4 different types of autism spectrum disorders:

• Autistic disorder (or autism)
• Asperger’s syndrome
• Childhood disintegrative disorder
• Pervasive developmental disorder - PPD

The variability of the symptoms and their intensity can make autism difficult to diagnose with accuracy. Frequently the diagnosis given is one of an Autism Spectrum Disorder (ASD). Another difficulty in the diagnosis is that the symptoms may be confused with those of other conditions or disorders such as global developmental delay, intellectual disability (intellectual developmental disorder), or child psychosis.

What are the signs and symptoms of autism?

Signs of social difficulties in children with autism:

Children with autism display a lack of socio-emotional reciprocity and hence difficulties in developing, maintaining and understanding relationships. It may seem like they live in their own world, distant and detached from others.

Typical signs and symptoms may be:

• Seeming uninterested in others or in what is happening around them
• Not knowing how to initiate interaction with others and communicate with them, difficulties playing with other children and making friends
• Preferring to be alone rather than participate in group activities
• Preferring to not be touched, held or hugged
• Being unable to play games that require "make believe" (e.g. playing with dolls or Playmobil), to imitate and to use toys in a creative way
• Difficulty understanding and talking about feelings
• Seeming to not hear when others talk about them
• Not sharing their interests or achievements with others, for example not showing drawings or toys.

Signs of difficulties in non verbal communication in children with autism:

Children with autism may present deficits in the non verbal communication behaviours used in interaction because they have difficulties decoding them. Consequently, social relations can be problematic and children with autism may:

• Avoid eye contact
• Use certain facial expressions that do not correspond with what they are saying
• Not understand the facial expressions, tone of voice and actions of others

Signs of rigidity in children with autism:

Children with autism are sometimes limited, rigid or even obsessive in their behaviour, activities and interests. The following behaviours may be observed:

Repetitive movements:

• Repeating the same actions or movements again and again - for example, hand clapping or rocking
• Abnormal posture, clumsiness or walking in an eccentric way such as on the tips of the toes
• Lining up or classifying objects in an obsessive manner, spending long periods of time organizing their toys in a specific way

Adherence to rituals and routines:

Following a rigid routine, for example insisting on a specific route to school or eating the same thing every day
Difficulty adapting to changes in schedule or environment for example, demonstrating extreme distress if furniture is moved or bedtime is changed

Unusual and intense or restricted interests:

• Fixation on numbers or symbols for example, memorizing maps, ferry timetables or sporting statistics
• Becoming very attached to unusual objects

Hyper or hypo-reactivity to sensory stimulus:

• Negative reactions to specific sounds or textures
• Hypersensitivity to loud noises
• Excessive smelling or touching of objects
• Apparent indifference to pain or temperature
• Fascination for lights or movement: spending long periods of time watching or making objects spin such as a ceiling fan or the wheels of a toy car, enjoying turning lights on and off

Signs of speech and language difficulties in children with autism:

Children on the autistic spectrum may have speech and language difficulties. They may:

• Start talking late for their age
• Speak with a particular tone of voice: speak with an accent or a monotone voice, end sentences as if they are asking a question
• Repeat the same words and phrases again and again (echolalia)
• Reply to questions by repeating rather than replying
• Refer to themselves in the third person rather than using "I"
• Use language incorrectly with grammatical errors or wrong meanings (use of the incorrect word)
• Have difficulty in communicating their needs or wishes
• Not understand instructions or simple questions
• Take things literally and not understand subtleties - difficulties understanding humour, irony or sarcasm

How to diagnose autism?

Let’s start by taking a look at how the brain works…

At any one point in time, our brain is carrying out complex procedures to gather and process the information it encounters. In order to do so, it uses what are known as "cognitive functions". Cognitive functions can be defined as the cerebral activities that lead to knowledge (cognition). They include all types of mechanisms for acquiring information, namely:

• Functions non-focused on emotions: reasoning, attention, memory, language, motor skills, planning etc.
• Functions focused on emotions: functions known as affective and social

It is thanks to the efficiency of our cognitive functions that we can participate in the world around us and learn. When a child has difficulties learning or being in the world, it means that there are deficits or at least difficulties with one or more of their cognitive functions.

Due to the complexity of the brain and it’s functioning, an exploration of the different capacities that may have an influence on the relationship with the world and learning, is essential. For example, children with autism often display varying difficulties that should be assessed, such as emotional, social, attention, language-based and mobility impairments.

Full Assessment of psychological functioning

Assessment for children aged over 6 years old

In case of a suspected autistic spectrum disorder, for children from the age of 6 and above, a full psychological and neuropsychological assessment should be carried out. The full assessment links together cognitive development with emotional and affective development.

* Neuropsychological assessment examines cognitive development. It analyses the totality of the cognitive (brain) functions. By exploring the symptoms displayed by the child, it enables deficits of any of the brains functions to be identified. It examines the following cognitive aspects of the child:

• Attention: selective, sustained, divided / visual, auditory, audio-verbal
• Executive functions: planning, flexibility, working memory, speed of information processing
• Language: expression and comprehension
• Memory: visual, verbal, visuospatial etc.
• Reasoning: verbal, perceptual, crystallised, fluid
• Social and emotional skills: perception and comprehension
• Visuospatial skills
• Motor skills

* Psychological assessment examines emotional development. It allows the psychologist to identify the specificities of a child’s personality and whether or not any disorder is present. It examines the following psychological aspects of the child:

• Level of personality organization
• Level of adaptation to reality
• Level of emotional adaptation
• Level of social adaptation
• Individual issues
• Emotional state

Assessment for children under the age of 6 years

If an autistic disorder is suspected before the age of 6, a developmental assessment can be carried out. This involves assessment of the child’s stage of development in relation to that of other children of the same age. The following aspects are examined:

• Motor skills: fine and gross
• Language: expression and comprehension
• Intellectual capacities
• Life skills
• Social skills
• Autonomy

A developmental assessment enables the detection of deficits as well as helping to make diagnostic hypotheses, to orient the therapeutic care plan as well as psychoeducational strategies at school and at home.

Under the age of 6, the child is in a stage of phenomenal neuronal and psycho-affective development. The diagnostic hypotheses based on the developmental assessment should be verified around the age of 6 once the brain functions are not in such a major phase of development.

As the brain functions are still in the process of developing, we cannot expect, for example, a 3-year-old to have fully developed attentional capacities and to be able to concentrate. For this reason, this cognitive cannot be assessed. Certain cognitive functions cannot be assessed before the age of 6.

Therefore, a full psychological and neuropsychological assessment at the age of 6 allows for the diagnosis to be confirmed or otherwise and for an evaluation of the totality of the cognitive functions in depth. In the meanwhile, psychological treatment can be offered to assist the child in their development.

Assessment objectives

The assessment helps to respond to several questions.

What difficulties is my child being faced with?

The evaluation allows for difficulties to be identified and for a diagnosis or diagnostic hypothesis to be proposed. It enables:

• Understanding the nature of the difficulties faced by the child: are signs of cognitive and/or emotional/affective/mental deficits present?
• Evaluating the severity of the deficits and the level of skills
• Examining the consequences on the psychological functioning and the autonomy of the child of these deficits or disorders: are they affecting learning, social interaction, emotional regulation? If so, how and to what extent?
• Ascertaining the resources available to the child that can help them to develop

How to deal with these difficulties?

The evaluation can guide the follow-up treatment and maximise the learning potential and well-being of the child. The objective is to help the child to flourish on all levels - academic, social and emotional. The evaluation helps:

• Parents to better understand their child, respecting the child’s limits and providing better adapted support
• To provide parents with the knowledge required to explain their child’s needs and get them help from the relevant services
• To develop an effective therapeutic care plan adapted to the child’s needs (benefiting from the services of neuropsychology, psychology, occupational therapy, speech therapy etc.)
• To develop an efficient individual education plan adapted to your child’s needs (psychoeducational strategies at school and at home, teaching assistants, collaboration with teachers etc.)
• To provide the child with a vocabulary that gives meaning to the difficulties faced. Better understanding of the causes of suffering can provide comfort. For example, a child who knows that they have difficulties learning or learns differently may feel like a failure. However if he or she understands their difficulties, they can accept them and approach things in a different way. The final stage is to help the child to feel capable of overcoming, to whatever extent is possible, their difficulties and therefore engaging in the treatment plans offered. Indeed, motivation is the central factor in the success of treatment.