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HEALTHWATCH

Sea of complexities

Photo: G. Moorthy

Lack of social skills: Helping children with autism react to social situations.

Anurag appeared to be a wonderful boy. He ran around the room like a non-stop express train. He climbed atop tables, chairs and windows and whirled around every conceivable place of the consultation room.

As the evaluation progressed, a few important details were recognised. He was least interested in people around and starting a conversation with him was like cracking a stone. He continually avoided eye contact and looked out of the window.

Simple questions, like “What is your name? Where is your father?”, were answered in an unusual manner. Often, he repeated the questions or his answers were completely irrelevant to the questions. Further methodological observations and assessments revealed that he had Autism spectrum disorders (ASD).

Although research on autism has come a long way from the time when Leo Kanner, a psychiatrist, first reported it in 1943, the disorder still remains a mystery. Majority of the research on autism concentrates on three main issues: Understanding the cause; Effective treatment programme; and early identification.

Most researchers now agree that autism is a neurobiological disorder of genetic origin. But, at the same time, other psycho-social factors, like lack of opportunity for social interaction during early age, aggravates the problem.

In India, only in the last decade have issues related to autism been discussed. A number of children are now being identified with autistic disorder. The term autism spectrum disorder is preferred over autistic disorder because it encompasses a wide range of symptoms with varied severity.

Often, parents are confused about the nature of the disorder. They go through agony rising from natural concerns like the child’s uncertain future, the cause of the disorder, confusion regarding treatment programmes, societal stigma... During interactions with parents, the sense of hopelessness is palpable.

Early identification and treatment programmes have helped straighten most of the unwanted twirls in the developmental period. Research has proved that training programmes for younger children yields better prognostic results than those for children in the older age groups. Also early identification can help alleviate parents’ worries.

Despite the importance of early identification, the disorder is often not diagnosed before three years of age. The primary reason could be lack of awareness.

Another reason could be the lack of trained professionals to assess such disorders in young children. Some parents delay consultations, as they are often confused about the potential abilities of their children because of the scatter in the developmental profile.

Unlike children with mental retardation, most children with autism can crawl, sit, walk at the right age and have good visio-spatial skills, short-term memory, topographical sense (sense of directions) and musical abilities. To make the condition more complex, some children may have an average or above average IQ even though the majority fall in the below average category. The severity also varies from mild to severe.

Another perplexing feature is that most children undergo a regression of acquired skills during the first three years. The regression can occur in speech, social interaction and other behavioural skills. This causes a huge heterogeneity in the symptom profile.

Variability in the symptom profiles makes one autistic child different from other. The most common difficulty reported by majority of the parents is delay in speech-language development and lack of social relationship.

Research has identified certain important markers for early recognition of autism. These include forms of communication, speech language development, types of play and other behavioural deviancies.

Normally children of less than one year use gestures to communicate their needs. Generally they point to distant objects as a means of request or shake their head to say no.

But in the case of children with autism, a lack of communication is a prominent early behavioural marker. They fail to maintain eye contact and show extreme disinterest in socialisation. And they do not use gestures as a means of communication.

Other social skills required for communication such as taking turns while vocalising, seeking attention from parents, showing off toys as means of socialisation also does not appear in children with autism in the first 18 months of life.

Reciprocal communicative behaviour is highly deficient. Children with autism often fail to respond to their name. When parents try to engage the children in games like hide and seek, clap hands, they fail to take turns.

Normally by 18 months children start to play with toys in an imaginative way. This includes putting the doll to sleep or starting an imaginary car.

This kind of pretend behaviour is highly deficient in children with autism. They tend to play in a highly non-functional manner. They might use the building blocks to create forms of various shapes. But play involving other children is highly deficient.

There is often a delay in speech-language development. The language developed may be characterised as echolalia (repeating what you say).

Some children show language marked by irrelevant speech. Peculiar speech forms such as “sun is wet” looking at a sunset are also observed.

Some children experience regression i.e. they would start to say a few words but lose it before 36 months. The regression can be seen in speech and other behavioural skills. There is no accurate explanation for this phenomenon.

Most times, stereotypic behaviours such as flapping hands, vacant staring, banging the head, inappropriate laughter/cry is seen in older children or when the symptoms are very severe.

Early identification is the first ray to light up the otherwise dark zones of autism. Lack of communication either through gesture or speech is one of the early markers for detection of autism.

An intensive training programme focussing on improving both means of communication helps these children to a large extent.

Therefore early identification and early treatment helps children with autism to swim across the sea of complexities.

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