Introduction

Autism spectrum disorder (ASD) is a developmental disability that can result in significant social, communication, behavioural difficulties . Although autism can be diagnosed at any age, it is considered a "developmental disorder" because symptoms typically appear within the first two years of life. Autism is referred to as a "spectrum" disorder because the types and severity of symptoms that children experience vary greatly.

People with ASD may communicate, interact, behave, and learn in ways in which are different from others. People with ASD have a good range of learning, thinking, and problem-solving abilities, starting from gifted to severely challenged. Some people with ASD require a lot of help in their daily lives, while others require less.

According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-V), a guide used to diagnose mental disorders, people with ASD have:

• Difficulties communicating and interacting with others

• Restrictions in interests and repetitive behaviours 

• Symptoms that impair a person's ability to function normally in school, work, and other areas of life

Causes

ASD's (Autism Spectrum Disorder) precise causes are unknown. According to research, genes can interact with environmental influences to influence development in ways that lead to ASD. Although scientists are still investigating why some people develop ASD while others do not, some risk factors include: 

1. Families with a history of ASD: Children from families with a history of the disorder are more likely to develop it. Even if neither parent has ASD, they may be carriers of gene changes that cause autism and can be passed on to the child. A child whose sibling has ASD is at a higher risk of developing ASD as well.
2. Genetic factors: People with certain genetic conditions, such as Down syndrome or fragile X syndrome, are more likely than others to have ASD.
3. Environmental factors: Exposure to certain foods, lead, alcohol, smoking, illicit drugs, and vaccines are all factors that contribute to the causes of Autism.
4. Having children later in life: Parents who have no family history of ASD but begin having children at a later age are at a higher risk of their children developing the condition. 
5.  Pregnancy complications: Pregnancy complications, such as multiple pregnancies and preterm births, are also factors. Furthermore, some research suggests that pregnancies separated by less than a year may put a child at risk of developing ASD. Children with very low birth weight are also at risk of developing ASD.

Severity Levels

According to the DSM V, there are severity levels for ASD based on the level of support required by the child with ASD.

Level 1: Require Support

• There are noticeable impairments in social communication. A child may be able to speak in proper/meaningful sentences at this level. Interactions, however, are missed.
• Difficulty initiating social interactions.
• There is a lack of 'to and fro' interaction flow between people.
• Lack of ability to socialise and make new friends.
• Inability to organise and formulate strategies. 

Level 2: Require Substantial Support

• A lack of verbal and nonverbal communication skills.
• There is little or no social interaction, and they do not respond to people who try to interact with them.
• Interaction is possible up to a point with nonverbal communication.
• Reduced ability to function and participate in daily activities.
• Obvious repetitive behaviour. 

Level 3: Require Very Significant Support

• Children have severe problems with verbal or nonverbal communication;
• They are less likely to reciprocate to social interaction;
• They rarely respond to people attempting to socially interact with them; and
• They have strong or extreme restrictive/repetitive behaviours. 

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Signs and Symptoms: How to identify Autism Spectrum Disorder (ASD)? (or) How can I know if my child has ASD?

Children’s social communication skills are developing as they grow and most children find it difficult to communicate their needs and feelings appropriately and tend to engage in repeated patterns of behaviours that can be stereotypical and show preference to do a set of activities over and over again.

However, for children with ASD persistent challenges with social communication, restricted interest and repetitive patterns of behaviours are quite evident before the child is 2-3 years of age and tend to cause functional difficulties leading to deficits in holistic development.

The following are the signs that can be observed in children with ASD.

General Signs of ASD:

• Persistent challenges in social communication and restricted patterns of behaviours (stereotypical behaviours) must be observed in multiple settings or contexts.
• Early signs of ASD can be observed in children before they reach the age of 1 year, however, the symptoms become visible and can be accurately demarcated only after the child is 2-3 years, as the child can be observed with peers of the same chronological age.
• Challenges in social communication and restricted and repetitive behaviours lead to functional impairments and affect the holistic development of the child. 

Challenges in Social Communication and Interaction can be seen major in three areas:

• Non- Verbal Communication - the ability to use gestures, facial expressions and body language to communicate.
• Social Relationships - the ability to build, develop and maintain relationships with others in the social environment. 
• Socio-Emotional Reciprocity - the ability to communicate back-and-forth in social interaction by understanding and responding to others in the social environment.

Challenges in Non-Verbal Communication:

• Difficulty maintaining eye contact.
• Avoiding or aversion in maintaining eye contact with others.
• Trouble accurately using and understanding non-verbal communication.
• Lack of proficiency in using non-verbal gestures for communication.
• Lack of integration between non-verbal and verbal communication.
• Lack of appropriate usage of facial expression.

Challenges in Social Relationships:

• Difficulty understanding different social relationships.
• Challenges in developing and maintaining social relationships.
• Difficulty making friends/peers.
• Lack of interest in peer interaction and association.
• Trouble maintaining/keeping friendships. 
• Challenges in sharing things and materials. 
• Difficulty adjusting behaviours to suit the requirements/demands of various social contexts.

Challenges in Socio-Emotional Reciprocity:

• Difficulty to engage in back-and-forth conversations.
• Challenges in reading and understanding the socio-emotional cues.
• Difficulty in initiating conversation.
• Trouble in responding appropriately to social conversations. 
• Difficulty in sharing interests and emotions.
• Difficulty appreciating their own and others’ emotions.
• Trouble in interpreting abstract concepts. 

Behavioural Challenges:

• Restricted, repetitive and ritualized patterns of behaviours.
• Inflexibility in behaviours affects the ability to cope with changes.
• Repetitive or stereotyped behaviours and motor movements - hand-flapping, echolalia (repetition of spoken words), rocking etc.
• Strong adherence and preference for routines - preference for sitting in the same place, taking the same route etc.
• Difficulty adapting to changes and making transitions.
• Restricted and fixated interest - focusing on one area/subject by excluding others.
• Preoccupation with unusual objects and their parts - like a box and the corners of the box.
• Arranging things in a peculiar or strange order.

Sensory Challenges:

• Hyper- or Hypo-sensitivity to sensory inputs.
• Sensory fixation - unusual interest in the sensory aspect of an object or environment - excessive touching or feeling of a particular object or visual fascination - responding to movements of light. 
• Adverse or unusual reaction to specific textures or sounds.

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Prevalence of ASD: How common is ASD? (or) How many children are affected with ASD?

Global Scenario:

The World Health Organisation (WHO) Report (2021) estimates that 1 in 160 children is expected to have ASD globally. WHO states that accurate prevalence of children with ASD cannot be estimated as the prevalence of children with ASD in middle- and low-income countries are still unknown as the children with potential ASD are not identified/diagnosed and the data is not available.

A report from the Centre for Disease Control and Prevention (CDC, 2016) revealed the following details:

• In developed countries about 1 in 54 children have been diagnosed with ASD.
• ASD is 4 times more prevalent in boys than girls.
• About 17% of children i.e., 1 in every 6 children is diagnosed with developmental disabilities which later turns out to be other neurodevelopmental disorders like ASD, ADHD, ID, etc.

Indian Scenario:

A research study by Katsnelson, A (2018)  revealed the following details: 

• In India, about 1 in 100 children below the age of 10 years show early signs of ASD.
• 1 in 8 children is estimated to develop one of the neurodevelopmental disorders like ASD, ADHD, LD, ID etc. during the life course.
• Compared to the last decade there is a rise in the number of children being diagnosed with ASD and experts feel that 2 to 6 children out of every 100 children below the age of 18 years are at-risk for ASD, however, goes undiagnosed.

Crucial Steps Involved in Early Detection of ASD

Key Aspects of Early Identification

The following steps are to be followed by caregivers, parents, and/or educators to ensure early identification of children with ASD so that early intervention can be designed to support the child’s needs.

Screening: 

If a child is suspected to display signs of ASD- the first step is to take the child for screening by administering an observation checklist to determine if the child is displaying red flag signs of ASD in terms of social communication, behavioural and sensory challenges that affect the child’s development and quality of life.

If these challenges of the child are persistent in multiple settings and impair the child’s performance and functioning, then a formal diagnosis from a certified/licensed professional would be needed to start early intervention. 

Formal Assessment or Diagnostic Evaluation:

Finally, the child needs to be taken for a 'Diagnostic Evaluation' to formally diagnose the condition by a certified/licensed professional to design early intervention to support the child and his/her needs.

Brief on Intervention - What can be done to support children with ASD?

Core Aspects of Early Intervention

A combination of the following interventions can be used to support children with ASD and their families. These interventions can be instrumental in improving the child’s functioning. 

Applied Behaviour Analysis (ABA) 

ABA focuses on systematically studying the functional challenges of children with ASD and designing an individualized behavioural plan to manage behavioural challenges, develop appropriate behaviours and adaptive skills in children with ASD. 

Social Skills Training 

Social Skills Training can be used to teach one or more appropriate social behaviours to children with ASD to help them adapt to and navigate social situations.

Speech and Language Therapy 

Speech and language therapy can focus on developing speech and communication patterns in children with ASD.

Occupational Therapy (OT)

OT helps in developing and strengthening adaptive skills in children with ASD to help them with activities of daily living (ADL).

Remedial Intervention or Special Education Services

Individualized Educational Plan (IEP) can be designed for children with ASD to help them accommodate in school settings and achieve their academic goals. 

Parental Management Training 

Parents are taught more about the condition and are equipped with effective techniques to deal with behavioural challenges of children with ASD and promote appropriate development of behaviours. 

ASD Support Groups

Support Groups are helpful to parents to connect with fellow parents who share similar experiences and concerns. This helps them to build networks, cope with the stressors and better deal with children with ASD by learning from one another.

Medication

Medications that have an effect on the central nervous system are prescribed by licensed clinicians to manage symptoms of ASD in everyday life. Finding the right medicine with the appropriate balance is crucial.