Diagnosis

The diagnosis of children with autistic spectrum disorders is based on a consideration of a so-called ‘triad of impairments’. This involves particular difficulties with the following three aspects of behaviour:

Understanding social behaviour.
Using and understanding verbal and non-verbal communication.
Imagination and flexibility of approach.
 

Understanding social behaviour

Children may show no interest in people, seem detached, avoid eye contact and prefer to be alone. They may not seek out affection in the normal way, and actively resist any attempts by others to hug them and kiss them. Some may want to have social contact, but do not really know how to approach people and how to behave and cannot make friends. They usually have difficulty in processing emotions, so they find it hard to manage their own emotions effectively and cannot understand those of others. They find it hard to understand why other people behave the way they do, and do not themselves manage to behave in a socially appropriate way.

Using and understanding verbal and non-verbal communication

Many children are very slow to acquire speech skills, and some remain non-verbal all their lives. Some may seem to be developing speech quite well, and subsequently lose it. As their speech develops it can often be used inappropriately. Echolalia is common, where children repeat words or phrases they have heard without attaching any particular meaning to them. Sometimes they will find it hard to choose appropriate language for a given situation and what they say sounds odd and out of place. Often they will find it hard to process instructions fully, and tend to interpret what they hear literally and without a social context. They are often unaware of the implications of changes in the tone of someone’s voice and their own speech can be wooden and lacking in intonation.

Non-verbal communication involves the use and interpretation of facial expressions and gestures, expressing feelings and emotions appropriately with their bodies and reading the body language of others correctly.

Imagination and flexibility of approach

Young children tend not to develop appropriate play skills. They may not play with toys in the accepted way, but may become fascinated with moving parts, spin things around or use them in a repetitive ritual. They may not develop normal imaginative play and at best play alongside other children rather than join them in their games. Sometimes they will play the same game time and time again. Many children become obsessed with routine and cannot tolerate any deviation from their normal schedule. They may develop obsessive interests which dominate their lives. They often find it very hard to adapt to new situations and may not easily generalise learning from one experience to another.

In addition to the triad of impairments, children on the autistic spectrum generally have a number of significant issues with sensory perception. They usually have more significant hypersensitivity than most children with learning issues, and this degree of over-stimulation often causes them to tune out and shut down completely, so that they become under-sensitive to some aspects of their sensory environment. With this level of impairment in the developing senses there are usually difficulties in nearly all areas of sensory development and sensory integration.

Pervasive Developmental Disorder (not otherwise specified)

This term is applied to children on the autistic spectrum who have significant problems but do not show difficulties with all three of the triad of impairments.

Case Histories

JACK

Presenting problems

Jack was diagnosed with ‘Pervasive Developmental Disorder (not otherwise specified)’. Although considered to be on the autistic spectrum, he did not warrant a diagnosis of autism because he did not have sufficient difficulties in all three areas of the autistic ‘triad of impairment’, which involves deficits in social interaction, communication and development of imagination. At five and a half years old, when he started his programme, he was attending a private school mornings only with a one to one helper. He could not read the simplest of books and had trouble even in focussing on a word. He had great difficulty with holding a pencil and could not form any letters properly; he could not write his name. His concentration was very poor and he would need constant one-to-one support to keep him focussed on any task.

Jack was prone to mood swings and would become easily frustrated. If he was not ‘in the mood’ it would be impossible to get him to do anything and he could become noisy and disruptive. When this happened, which it did quite regularly, he would have to be removed from the classroom to allow him to calm down. He was unable to listen to instructions and could not do anything independently. He did not interact with the other children and preferred to keep himself apart. In fact, he was intolerant of other children and their ideas and would display aggressive behaviour when asked to cooperate with them. Incidences of punching and kicking had resulted in both children and staff being hurt. The school did not feel that they were suitably equipped to deal with Jack’s needs.

Assessment

As might be expected from Jack’s diagnosis, he had severe deficits in all the underlying developmental sub-systems, which resulted in his visual, auditory and motor development being extremely immature. He had also not been able to develop the skills of social communication and social interaction, although he could make eye contact, he enjoyed rough and tumble and he was capable of imaginative play. There may well have been some chinks of ability, but he was so hyperactive and inattentive that it was impossible to pin him down to get him to complete any tests at a level where you could be sure he had done his best, and he would quickly become frustrated with a task.

Progress

Jack did remarkably well on the therapy programme. He moved to a little private school into a class of five a few months after he started the programme, in the year below his age. Five months into the programme he was starting to read, his number work was very good and his writing was coming on in leaps and bounds. It was discovered that he had a beautiful singing voice, and he started having singing lessons. Seven months into the programme he was a shepherd in the school nativity play and there were no hitches. A few months later his mother commented that he was doing very well socially, and after just over a year he was able to join in fully with the fun day and sports day at the end of the school year. He had a brilliant report and won the school progress prize.

Nineteen months after the start of the programme the school asked if they could put him up into his own year group because they thought he could be lazy unless pushed. At that point all his obsessions had gone. Within a year he had not only caught up with his age group but he was top of the class in comprehension, and not one of his exam marks was low.

STUART

Presenting problems

Stuart was nearly five and diagnosed with mild to moderate autism when he was three and a half. He had some speech, but only used language to communicate his needs, not for social communication. He could repeat what he heard, and could hold a tune well, but could not really respond to questions. There were problems with his visual functioning also. He would look at things from the corner of his eye and could not sustain eye contact. He had a very short attention span and did not play with toys appropriately. He would have a temper tantrum if he did not get his own way and would often bang his head on the floor when frustrated. In general his emotional responses were inappropriate. He had a severe reaction to change and he could be very obsessive. He needed help with toileting and dressing.

In spite of his difficulties, Stuart was placed in a mainstream school with support, including a daily language programme. This was in accordance with his parents’ wishes. The school were very supportive. He would do more or less what others did in the classroom with a lot of coaxing but he was unaware of the other children and played alone. He would sit with the others in circle time, but he could just get up and walk off, treading on any children in his path.

Assessment

Due to Stuart’s age and the level of his difficulty the only assessment possible was through questionnaire and observation. On this basis it was clear that Stuart had a huge tactile sensitivity. He was very intolerant of haircuts, face washing, finger nail cutting and hated loose threads or anything sticky, dirty or sandy. It was hard to apply lotions to his skin, and he hated his hand being held. He was happiest if he had no clothing next to his skin, and would disrobe entirely given the opportunity. His tactile sensitivity caused him to have established food preferences based on the texture of food and he would not eat vegetables. At the same time, he had an extremely high pain tolerance before the introduction of the gluten free, casein free diet some time previously. His temperature control was also affected, and he would insist on wearing a jacket even on very warm days.

Stuart had major problems with listening. He was oversensitive to sounds, could not listen to instructions or understand discussions or requests and seemed to have no recall of what had been said. He had a very short attention span, was easily distracted and needed a lot of repetition and clarification. He would get very tired if he had to listen for long periods. He found it hard to express himself too. He had problems with articulation and fluency, jumbled up phrases and had difficulty finding the right word. He did not use meaningful speech except to communicate his needs.

Stuart’s visual processing was clearly unusual because he would look at objects out of the corner of his eye. He found it hard to catch a ball and his eyes got very tired if he was asked to focus on a book. His balance was also strongly affected. He would spend a lot of time watching things spin, or spinning himself but he avoided the merry-go-rounds and swings that children normally enjoy. He would also bang his head a lot. Stuart’s 'body in space' awareness was poor too. He felt disorientated in the shower and reacted with hysteria to having his hair washed. He hated crowds and would not accept physical boundaries.

Stuart had major difficulty with any tasks involving brain integration. He had crawled, but had not sucked well as a baby. Language and comprehension were severely delayed, visual interaction was abnormal, dressing skills were weak, fine motor skills were immature, organisational skills were very limited and he did not have much concept of consequences. Lateralisation was consequently affected, so he had been late to settle his handedness and seemed to have no idea of left and right. There was very little basis for the development of language and literacy skills and the social interaction expected in a normal infant classroom.

Progress

After a month on the programme Stuart was much calmer, trying to speak more and sleeping longer. He was more aware, but more sensitive to noises. After two months he had begun to love water, and it was now possible to wet his head and face. He would now sit well at restaurants. He had started to speak Polish to his polish aunts. He could still be quite moody, banging the floor and screaming. He was noticing a lot more and much more aware of people, calling them all by name now. He was now much more demanding, however. After three months he was engaging in a lot more imaginative play and there was a general improvement in his behaviour at school. He was trying to communicate a lot more now, and there was much more social interaction. Mum could now wash his hair without difficulty.

After four months he had a much bigger vocabulary and was building five to six word sentences. He was very quiet and very good, and would even endure a three hour shopping trip. His sense of humour was beginning to come through and he was developing a personality. At school he was very settled and they were having no problems with behaviour. Over the following month he went through a bad patch. There were a lot of tantrums and he could be very agitated and frustrated. There had not been the expected further improvement in his speech. There were wet patches on his pants and he wet the bed at night. The following month he was still tending to wet the bed, but his behaviour had settled. He was now much more aware of what was going on around him and he would eat a whole range of vegetables – carrots, broccoli, cabbage, peas.

After seven months on the programme Stuart was taking showers and had a natural smile. He was enjoying a big kiss and a cuddle at night for the first time. He was much more aware of his surroundings and trying hard to express himself. If something had happened during the day at school he would try to tell his mother about it. He was much less bothered about things and much easier to manage. The following month Stuart’s communication skills were continuing to develop and he was enjoying playing with other children. Reading skills were developing well and he had read a whole book for the first time. He was still wetting the bed five nights out of seven.

Nine months after the start of the programme Stuart’s play skills had developed to the point where the school were able to put a programme in place to speed up his maturity. Three children from his year were asked to play with him each day, and he cooperated well with their games. His communication skills were improving all the time, and he was much more relaxed and stable. His teacher said that he was doing so well that everyone was impressed. In class he was making exceptional progress. He had much better stamina, his maths was good and he was getting his spellings right. He was reading well, his enunciation was clear and he was attempting full sentences. He was doing so well that the programme that had been organised for him at the beginning of the year had to be changed. At home he had also developed a good appetite, but he was still wetting the bed and he would often wake and come into his parents room at 4 to 5 a.m.. By the following month he was not waking until six. His writing had improved greatly and was much neater. He had started to draw pictures with some prompting.

A report from the school the following month found no problems. He was no longer wandering off and was independent at lunch time. He was a lot more talkative, although quite loud, and had started asking questions. He had a bubbly sense of humour. He was talking in full sentences and colouring in his pictures. His reading was age appropriate but comprehension was relatively poor. He was playing with a wider variety of toys and more interactive. At home he was showing more frustration and throwing some tantrums, but his behaviour in church was a lot more appropriate. His eye contact was improving all the time and he was settling down to sleep much better. He had stopped wetting the bed and no longer banged his head.

By the end of the school year he had an excellent report from school, but they wanted to reduce his support in class because he was doing so well. He was learning the time from his new watch, there were no behaviour problems and he was described as aware and capable although he did not always pay attention. He was now enjoying listening to stories – he had refused to listen three or four months previously - his facial expressions were normal and he was very popular in class. He was now capable of feeling embarrassment and knew when people were sad. The educational psychologist wanted to know what programme he was on, but didn’t pursue it!

Stuart started the following school year well. He had become quite a chatterbox and was much more assertive. As the term went by his communication skills continued to develop. He was really present in current time and conversed normally. He was asking a lot more questions. He was watching a wide variety of TV programmes and enjoying playing with lots of DVDs. He was now so attached to a favourite cuddly toy that he was sleeping with it every night. There were more behaviour problems at home however. He was pushing hard, but this time when he had a tantrum he clearly knew what he was doing. By the end of the autumn term he had a brilliant report and his teacher said that he was not like any autistic child she had ever come across. He no longer registered as autistic on the Autism Rating Scale. He loved school and was well liked. He appreciated the fun of Christmas for the first time. He was getting nearly all his spellings right and his concentration in class was much better. He still enjoyed his DVDs, but would be asking a lot of questions about the content, and would say who he liked and why. He used to be very indifferent to people, but now in school he was picking his favourite friends.

At Easter he went skiing for the first time and loved it. By the middle of the week he was skiing independently. His understanding was continuing to mature and it was now possible to reason with him. It was also possible for Stuart to cope with some formal testing to investigate his processing difficulties and it was clear that there were speech and language difficulties. He could not cope with “yesterday, today and tomorrow” for example, nor with questions in the past tense. His phonological processing and short-term auditory memory were very poor and his vocabulary skills were in the first centile.

Stuart could compensate for poor auditory processing ability with much stronger visual processing skills. His visual sequential and visual associative memory were well above average, although his visual spatial functioning was poor. His non-verbal reasoning ability, which makes heavy demands on brain integration, was below average, although when it was tested seven months later it had reached the average level.

By the middle of the year Stuart had become quite cheeky and was much more normal. He had learnt how to lie! He was shouting a lot and would not give way – standing up for himself. His parents were seeing differences every day. Words were coming out in longer and longer sentences. He was very bubbly and agreeable, no tantrums and more communicative about his frustrations. He could now hold his concentration and enjoyed social interaction. He had a particular friend at school although he could still be phased by coping with children in an unfamiliar environment. He was now reading very well and understanding what he had read. He had the same spellings as the rest of the class and was doing very well.

At about this time Stuart’s mother’s health started to deteriorate. She developed hay fever and a rash on her eyelids, and her arm became inflamed. She began to struggle with a seafood allergy, became sensitive to the sun and was always tired. She was working for accountancy exams, so this could have increased her stress levels. However, we have noticed at Edutherapy that health issues always seem to develop in the mother of a formerly autistic child when she realises her child is going to be OK. She was put on the programme and soon recovered and later passed all her exams.

Over the following year Stuart continued to make progress but he did not need to come to see us very often. He learnt to ride his bike and was gradually losing his obsession with wheels, although he still loved cars. He was not looking at toys so much with his peripheral vision now, although it could still happen. There was also still the occasional wet bed. He was enjoying visits to the cinema now – it had not been possible to take him before due to the sensory overload. In general he was now happy to go out with people where previously he would have been scared. He was going to Beavers and loving it. In school he was following the mainstream curriculum although he still had support. Times tables were a bit of a problem. He had the same homework as everyone else and the school were planning to reduce his hours of support.

At the end of his third school year Stuart was awarded a silver plate for “Highest Achiever of the Year”, the highest school award. Only one silver plate is awarded each year.