Autism spectrum disorder (ASD) refers to a group of complex neurodevelopment disorders characterized by repetitive and characteristic patterns of behavior and difficulties with social communication and interaction. The symptoms are present from early childhood and affect daily functioning.

The term “spectrum” refers to the wide range of symptoms, skills, and levels of disability in functioning that can occur in people with ASD. Some children and adults with ASD are fully able to perform all activities of daily living while others require substantial support to perform basic activities. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5, published in 2013) includes Asperger syndrome, childhood disintegrative disorder, and pervasive developmental disorders not otherwise specified (PDD-NOS) as part of ASD rather than as separate disorders. A diagnosis of ASD includes an assessment of intellectual disability and language impairment.

ASD occurs in every racial and ethnic group, and across all socioeconomic levels. However, boys are significantly more likely to develop ASD than girls. The latest analysis from the Centers for Disease Control and Prevention estimates that 1 in 68 children has ASD.

What are some common signs of ASD?       

Even as infants, children with ASD may seem different, especially when compared to other children their own age. They may become overly focused on certain objects, rarely make eye contact, and fail to engage in typical babbling with their parents. In other cases, children may develop normally until the second or even third year of life, but then start to withdraw and become indifferent to social engagement.

The severity of ASD can vary greatly and is based on the degree to which social communication, insistence of sameness of activities and surroundings, and repetitive patterns of behavior affect the daily functioning of the individual.

Social impairment and communication difficulties
Many people with ASD find social interactions difficult. The mutual give-and-take nature of typical communication and interaction is often particularly challenging. Children with ASD may fail to respond to their names, avoid eye contact with other people, and only interact with others to achieve specific goals. Often children with ASD do not understand how to play or engage with other children and may prefer to be alone. People with ASD may find it difficult to understand other people’s feelings or talk about their own feelings.

People with ASD may have very different verbal abilities ranging from no speech at all to speech that is fluent, but awkward and inappropriate. Some children with ASD may have delayed speech and language skills, may repeat phrases, and give unrelated answers to questions. In addition, people with ASD can have a hard time using and understanding non-verbal cues such as gestures, body language, or tone of voice. For example, young children with ASD might not understand what it means to wave goodbye. People with ASD may also speak in flat, robot-like or a sing-song voice about a narrow range of favorite topics, with little regard for the interests of the person to whom they are speaking.

Repetitive and characteristic behaviors
Many children with ASD engage in repetitive movements or unusual behaviors such as flapping their arms, rocking from side to side, or twirling. They may become preoccupied with parts of objects like the wheels on a toy truck. Children may also become obsessively interested in a particular topic such as airplanes or memorizing train schedules. Many people with ASD seem to thrive so much on routine that changes to the daily patterns of life — like an unexpected stop on the way home from school — can be very challenging. Some children may even get angry or have emotional outbursts, especially when placed in a new or overly stimulating environment.

How is ASD diagnosed?

ASD symptoms can vary greatly from person to person depending on the severity of the disorder. Symptoms may even go unrecognized for young children who have mild ASD or less debilitating handicaps. Very early indicators that require evaluation by an expert include:

• no babbling or pointing by age 1
• no single words by age 16 months or two-word phrases by age 2
• no response to name
• loss of language or social skills previously acquired
• poor eye contact
• excessive lining up of toys or objects
• no smiling or social responsiveness

Later indicators include:

• impaired ability to make friends with peers
• impaired ability to initiate or sustain a conversation with others
• absence or impairment of imaginative and social play
• repetitive or unusual use of language
• abnormally intense or focused interest
• preoccupation with certain objects or subjects
• inflexible adherence to specific routines or rituals

Health care providers will often use a questionnaire or other screening instrument to gather information about a child’s development and behavior. Some screening instruments rely solely on parent observations, while others rely on a combination of parent and doctor observations. If screening instruments indicate the possibility of ASD, a more comprehensive evaluation is usually indicated.

A comprehensive evaluation requires a multidisciplinary team, including a psychologist, neurologist, psychiatrist, speech therapist, and other professionals who diagnose and treat children with ASD. The team members will conduct a thorough neurological assessment and in-depth cognitive and language testing. Because hearing problems can cause behaviors that could be mistaken for ASD, children with delayed speech development should also have their hearing tested.

What causes ASD?

Scientists believe that both genetics and environment likely play a role in ASD. There is great concern that rates of autism have been increasing in recent decades without full explanation as to why. Researchers have identified a number of genes associated with the disorder. Imaging studies of people with ASD have found differences in the development of several regions of the brain. Studies suggest that ASD could be a result of disruptions in normal brain growth very early in development. These disruptions may be the result of defects in genes that control brain development and regulate how brain cells communicate with each other. Autism is more common in children born prematurely. Environmental factors may also play a role in gene function and development, but no specific environmental causes have yet been identified. The theory that parental practices are responsible for ASD has long been disproved. Multiple studies have shown that vaccination to prevent childhood infectious diseases does not increase the risk of autism in the population.

What role do genes play?

Twin and family studies strongly suggest that some people have a genetic predisposition to autism. Identical twin studies show that if one twin is affected, then the other will be affected between 36 to 95 percent of the time. There are a number of studies in progress to determine the specific genetic factors associated with the development of ASD. In families with one child with ASD, the risk of having a second child with the disorder also increases. Many of the genes found to be associated with autism are involved in the function of the chemical connections between brain neurons (synapses). Researchers are looking for clues about which genes contribute to increased susceptibility. In some cases, parents and other relatives of a child with ASD show mild impairments in social communication skills or engage in repetitive behaviors. Evidence also suggests that emotional disorders such as bipolar disorder and schizophrenia occur more frequently than average in the families of people with ASD.

In addition to genetic variations that are inherited and are present in nearly all of a person’s cells, recent research has also shown that de novo, or spontaneous, gene mutations can influence the risk of developing autism spectrum disorder. De novo mutations are changes in sequences of deoxyribonucleic acid or DNA, the hereditary material in humans, which can occur spontaneously in a parent’s sperm or egg cell or during fertilization. The mutation then occurs in each cell as the fertilized egg divides. These mutations may affect single genes or they may be changes called copy number variations, in which stretches of DNA containing multiple genes are deleted or duplicated.  Recent studies have shown that people with ASD tend to have more copy number de novo gene mutations than those without the disorder, suggesting that for some the risk of developing ASD is not the result of mutations in individual genes but rather spontaneous coding mutations across many genes.  De novo mutations may explain genetic disorders in which an affected child has the mutation in each cell but the parents do not and there is no family pattern to the disorder. Autism risk also increases in children born to older parents. There is still much research to be done to determine the potential role of environmental factors on spontaneous mutations and how that influences ASD risk.

Do symptoms of autism change over time?

For many children, symptoms improve with age and behavioral treatment. During adolescence, some children with ASD may become depressed or experience behavioral problems, and their treatment may need some modification as they transition to adulthood. People with ASD usually continue to need services and supports as they get older, but depending on severity of the disorder, people with ASD may be able to work successfully and live independently or within a supportive environment.

How is autism treated?

There is no cure for ASD. Therapies and behavioral interventions are designed to remedy specific symptoms and can substantially improve those symptoms. The ideal treatment plan coordinates therapies and interventions that meet the specific needs of the individual. Most health care professionals agree that the earlier the intervention, the better.

Educational/behavioral interventions: Early behavioral/educational interventions have been very successful in many children with ASD. In these interventions therapists use highly structured and intensive skill-oriented training sessions to help children develop social and language skills, such as applied behavioral analysis, which encourages positive behaviors and discourages negative ones. In addition, family counseling for the parents and siblings of children with ASD often helps families cope with the particular challenges of living with a child with ASD.

Medications: While medication can’t cure ASD or even treat its main symptoms, there are some that can help with related symptoms such as anxiety, depression, and obsessive-compulsive disorder. Antipsychotic medications are used to treat severe behavioral problems. Seizures can be treated with one or more anticonvulsant drugs. Medication used to treat people with attention deficit disorder can be used effectively to help decrease impulsivity and hyperactivity in people with ASD. Parents, caregivers, and people with autism should use caution before adopting any unproven treatments.

Non-verbal difficulties include difficulty in understanding social context, empathising with others and appropriately interpreting social cues, body language and facial expressions. Gestures are often stiff, stilted or over-exaggerated.

Problems with social behaviour will sometimes arise from difficulties with understanding the changing context of social situations and with theory of mind or understanding the intentions of others. This may present as difficulties in interpreting facial expression, gestures and vocal intonation. Also, as pupils with ASD tend to be literal thinkers, they will have problems with knowing the rules that govern social behaviour and understanding jokes or idioms.

Pupils with ASD can become anxious with changes in routine and have problems with sharing attention, turn-taking and with interactive, imaginative play with others.

Therefore, difficulty with participating in the activities or enjoyment of others is a particular challenge to teachers as it affects the student’s ability to share and have varied interests, adapt behaviour according to the situation, accept changes in rules and routines, accept others’ points of view, and generalise learning.

Pupils with ASD may also experience erratic sleep patterns, display unusual eating habits, engage in self-injurious or aggressive or hyperactive behaviour, exhibit an unusual posture or gait, and have irrational fears or phobias.

Teachers need to understand the strengths and difficulties experienced by each individual with ASD, in order to provide for effective teaching and learning for each pupil.

Strategies for Learning and Teaching

These interventions include

• Early intensive behavioural interventions
• Structured play groups
• Cognitive behaviour interventions
• Antecedent-based interventions
• Task analysis
• Functional communication training
• Social Communication training
• Joint attention
• Naturalistic intervention or naturalistic teaching strategies
• Modelling
• Exercise
• Picture exchange communication system
• Reinforcement
• Visual support
• Scheduling
• Social Skills Training

Evidence-Informed Instructional Interventions for Students with Autism Spectrum Disorder

Strategies for Developing Social Communication and Social Interaction

• Be aware of the importance of play as a means of developing social communication
• Establish a relationship with the pupil based on consistency and predictability, developing the pupil’s trust and confidence
• Structure opportunities for the pupil to play alone, with a partner, in small groups and in larger groups
• Enable the pupil to make choices and develop independence within the overall framework
• Support the pupil through activities she/he finds challenging
• Identify effective rewards and reinforcers
• Help pupils to recognise their own feelings and the feelings of others
• Structure activities and routines using visual prompts
• Specific social interaction skills need to be taught, using real social situations. Remember that pupils with ASD are literal thinkers and they are often confused by the rules that govern social behaviour
• Adopt reverse inclusion and ‘buddy systems’ as a feature of inclusion policy and practice
• Help the pupil to understand the value of communication and why we communicate
• Use visual material and/or signing to support and facilitate the pupil’s communicative initiations and responses
• Secure the pupil’s attention prior to issuing instructions/engaging in conversation.
• Teach the social aspects of language such as turn taking and timing (some turn taking activities may include board games, hitting a balloon back and forth, telephone conversations, bouncing a ball back and forth, etc.)
• Teach gestures, facial expressions, emotions, vocal intonation and body language
• Always refer to the pupil by name as he/she may not realise that ‘everyone’ includes them
• Keep verbal instructions brief and simple and support with visual when possible
• Structure opportunities for pupils to practice skills in different situations
• Use stories to teach social communication/interaction.
• Develop social skills programmes to include peers
• Directly teach jokes, puns and metaphors

Strategies for Restrictive, Repetitive Behaviours, Interests and Activities

• Pupils must be helped to cope with new and/or varying activities
• Use object, visual or written timetables
• Structure the classroom environment to reduce distractions
• Provide structures that assist pupils in understanding the duration of tasks.
• Implement structured and systematic programmes to develop the pupil’s fine and/or gross-motor skills.
• Pre-empt the pupil’s anxiety that results from being presented with unstructured or unfamiliar situations without prior warning/explanation.
• Be aware of the difficulties for pupils inherent in less structured situations such as break, lunchtime, in the corridor and in transitions between lessons
• Build in calming and relaxing periods or movement breaks throughout the child’s day
• Devise and implement a structured play/leisure programme.
• Teach play scripts
• Make adjustments to the classroom to address the pupil’s under sensitivity/oversensitivity to noise, smell, taste, light, touch or movement.
• Elicit relevant information regarding the pupil’s eating, drinking and sleeping irregularities.
• Develop the role of ICT in meeting the pupil’s needs  associated with ASD and facilitating all curriculum areas
• Understand the function of behaviour which may be challenging
• Teach alternative, appropriate behaviours such as asking for help, asking for a break, completing a calming activity or using relaxation techniques

Collaborate with all stakeholders to develop Individual Educational Plans that focus on the pupil’s communication, social and behavioural needs and on providing access to the curriculum