There are those who have very firm beliefs as to the cause and who may disagree with some of the theories I shall be presenting. However, I will not judge the different theories. Nor will I delve deeply into the research methodologies that have been used in formulating those theories. I shall merely present them in what I hope will be a fair and easily understandable way and leave others to draw their own conclusions.

What is Autism?

Autism is a much misunderstood condition. Many people have seen the film Rainman and believe that the character portrayed by Dustin Hoffman is what all autistic people are like. In fact, the character in that film is not at all typical of the vast majority of those with autism. Others are under the impression that all autistics are “thick and stupid”. Again, that is a false belief.

Autism is a severe neurodevelopmental disorder characterised by qualitative impairment before the age of three in verbal and nonverbal communication, reciprocal social interaction, and a markedly restricted repertoire of activities and interests (American Psychiatric Association, 1994).

The condition was first described by the Austrian-American psychiatrist Leo Kanner in the USA in 1943. Kanner's case studies included children with marked delays in language acquisition and/or severe cognitive impairments. These impairments present as a delay in, and deviance from, the normal patterns of development occurring in three specific areas of behaviour:

• Social relationships and interactions
• Language and communication.
• Activities and interests.

These three areas of behaviour are referred to as the “triad of impairments”. As the severity of the symptoms can vary depending on the individual, autism is now more commonly known as Autism Spectrum Disorder (ASD). That is to say, any given individual may present with any of the impairments in varying degrees, but all three must be present for the condition to be ASD.

Although the presence of the triad of impairments is essential for a diagnosis of ASD there are other possible associated disorders. These include:

• over-sensitivity to sound
• aversion to a gentle touch but pleasure from firmer pressure
• poor motor coordination
• over- or under-activity
• abnormal moods such as excitement and unhappiness
• abnormal eating, drinking or sleeping
• problems with formal language including difficulty with comprehension and correct use of speech
• physical disabilities such as sensory impairment or epilepsy
• psychiatric conditions such as anxiety, catatonia or depression
• behavioural problems such as withdrawal, aggression, running away, self-harm or random screaming/shouting
• developmental disorders affecting language, reading, writing, numbers, etc.

As all of the above can be indicative of alternative problems they cannot, individually or severally, be taken as evidence of ASD but may be present in addition to the triad.

Around 10% of people with autistic disorders have a special skill or ability; much higher than the rest of their abilities would suggest. These special abilities can be, for example, in art, music or mathematics. This can be particularly evident in those with the higher functioning form of ASD known as Asperger's Syndrome and it has been known for them to memorise entire train or bus timetables, facts about soap opera characters and the actors/actresses who play them, all football results for the year, and the exact dimensions of buildings such as cathedrals. I personally knew a young lad who knew just about everything there is to know about all the fighter aircraft in service worldwide since the outbreak of WWII.

Diagnosis

Because of the variable nature of the symptoms, diagnosis of ASD can be difficult. A child who fastidiously arranges his toys in a particular order, or who reels off facts about cars or aircraft at inappropriate times or in a repetitive way may not arouse suspicions even though these can both be indicative of ASD. Avoidance of eye contact may be an obvious pointer to some kind of social impairment, whereas eye contact that is merely inappropriate may not.

As Cathie Scothorne, GP, says about recognising the signs of ASD “It is easier to describe a pain in the leg than a feeling that something is not quite right”.

Specific disorders, such as in the area of language development or limb coordination, may be diagnosed whilst the triad of impairments is overlooked; the diagnosed condition taking away the clinician's focus from the triad. This can be especially true in adults who come to the attention of the psychiatric community and whose condition was not diagnosed when they were young.

The World Health Authority (WHO) has produced a list of sub-groups of Pervasive Developmental Disorders (PDDs) that include autism and Asperger's Syndrome. Similar sub-groups, albeit with different names, can also be found in DSM-IV, produced by the American Psychiatric Association (APA). There is a reluctance among some clinicians to diagnose ASD unless the criteria for inclusion in one of these sub-groups is met. Additionally, WHO and the APA define Asperger's Syndrome differently from Asperger himself..This can lead to confusion. As a consequence, many clinicians will diagnose symptoms as indicating Pervasive Development Disorder - Not Otherwise Specified (PDD-NOS)¹ rather than as an autistic disorder.

1 Social relationships and interactions

Although most individuals with ASD enjoy certain forms of physical contact and demonstrate attachment to parents or carers, they can be aloof and indifferent. This is often mistaken as a lack of feelings for the person concerned.

In less severe forms, the individual may passively accept social contact and demonstrate pleasure from doing so. However, they are unlikely to make spontaneous approaches to people. Those that do display such spontaneity may do so in what appear to be strange ways. Their approaches may be inappropriate or repetitive and they often pay little or no regard to the way the approached person reacts.

Higher-functioning adults with ASD may have developed an overly formal manner of interacting with others; including family and friends.

2 Language and communication

It has been suggested that underlying the social impairment of ASD is a lack of ability to understand that other people have thoughts and feelings – this is sometimes referred to as an absence or impairment of a Theory Of Mind².

A lack of understanding of the social uses of communication is always present with ASD. It is said that those autistics who do have the faculty of speech talk at people rather than with them.

They can fail to understand that language is a means of conveying information to other people. They are able to ask for things to satisfy their own needs but cannot comprehend that other people have feelings and needs as well. A lack of understanding of body language, facial expressions or gestures adds to this problem.

Some higher-functioning autistics who do use language can use it inappropriately. Their use of language can be very pedantic and they may demonstrate an inability to understand idioms. In addition autistics will very often take what is said absolutely literally, so care must be taken. There was a good example of this in Rainman where Raymond, the main character, was crossing a road. He got halfway when the sign changed to say “Don't walk”. He immediately stopped right there in the middle of the road.

Sufferers of ASD can become fascinated with words and word games but they fail to recognise that language is basically a tool for communicating with others in socially interactive ways.

3 Activities and interests

The vast majority of autistics desire a strict adherence to routine. Activities must take place at a certain time and in a rigid sequence. Any deviation can cause great distress which can manifest in a number of different ways.

When engaged in an activity they can be ultra-perfectionists. If what they are doing is less than perfect, even in the tiniest detail, it is often discarded and the activity re-started from scratch. It is very rare for an autistic to attempt to rectify a mistake as that would mean a break from the routine. Each step must be taken in a strict sequence.

An example of this was a man in his early 20s who was cataloguing his video collection. He was putting sticky labels on each tape to identify it. If the label was not millimetre perfect in its placement, or it was not exactly square to the side of the tape box, he smashed the tape and threw it away rather than peel the label off and apply a new one.

Autistics often develop a very narrow field of interest and show little or no inclination to learn about anything else. I have already mentioned the young lad I knew who was interested in fighter aircraft; but that was all he cared about. Other aircraft held no interest for him whatsoever.

Conclusion

It can be seen from the above that ASD can present in a multitude of different ways and that is why it can sometimes be very hard to diagnose. It has been suggested that the apparent rise in the incidence of ASD is due to better diagnosis by clinicians and that the rate is not actually rising at all. That matter is still being researched and I shall not go deeper into the debate.

In days gone by, and not that long gone by either, autistics would be shut away in psychiatric hospitals never again to see the light of day. I am glad those days are gone, but a lot still needs to be done to raise public awareness of this condition.

Notes

1.Pervasive Developmental Disorder - Not Otherwise Specified, also known as atypical personality development, atypical PDD, or atypical autism, is a sub-threshold condition in which some, but not all, of the impairments of ASD, or any other defined Pervasive Developmental Disorder, are present.

2. The Theory Of Mind will be discussed in a subsequent article.