Last reviewed 2 April 2020
Autistic spectrum disorder (ASD) is a medical term used to describe a range of developmental conditions which begin in childhood and affect the way a child communicates and relates to others, as Martin Hodgson explains.
Over the years, a wide range of different terms have been used for autism, including terms such as atypical autism, classic autism, pervasive developmental disorder (PDD), high-functioning autism (HFA), Asperger syndrome and pathological demand avoidance (PDA). However, ASD is now the most common diagnostic umbrella term because ASD symptoms can vary considerably from person to person.
All people with ASD share certain difficulties, but autism will affect them in different ways and may range from mild to severe. What is common is that all those on the autism spectrum tend to have problems with social interaction and communication and may see the world in a different way to other people. Some will also have additional learning disabilities, mental health issues or other health issues.
Many people still commonly use the term Asperger’s to describe a distinctive form of autism where children may have fewer problems with language than other children with ASD and no associated learning disability. Such children sometimes have average or above-average intelligence and particular skills in areas that require logic, memory and creativity, for example, maths or music.
In England, it is estimated that one in every 100 children has an ASD, with boys being three to four times more likely to be on the autism spectrum than girls. The incidence has increased considerably over the past 20 years, but this may simply be due to health professionals diagnosing more cases as ASD.
Symptoms of ASD can begin to show between 6 and 18 months of age. These may be difficult to spot, but can include:
gaze aversion — a baby may avoid or have limited eye contact or may not follow the gaze of his or her parent
a lack of a “happy response”
a failure to “babble” when talked to or to respond to voices
a lack of gestures such as pointing or waving.
In pre-school children, symptoms are often grouped into:
problems and difficulties with social interaction
impaired language and communication skills
unusual patterns of thought and physical behaviour.
Social interaction difficulties usually show themselves as a lack of understanding and awareness of other people’s emotions and feelings. Some children on the autism spectrum may have little or no awareness of other people or interest in other children of the same age. Others may try to form friendships but their inappropriate behaviour leads to these relationships breaking down and they find themselves playing alone.
Taking part in shared activities may also be difficult. Children on the autism spectrum often lack the concept of “taking turns” and their sense of play may be affected. Their play may lack imagination and may be repetitive in nature, often involving play with household objects rather than with toys.
Impaired language and communication skills are commonplace. Delayed language development and an inability to start conversations or take part in them properly are probably the most common problems. Some children may not speak at all. Some may appear to have normal language skills but their speech may be monotonous or flat, repetitive or non-conversational. Some will tend to repeat words or phrases spoken by others without formulating their own language (echolalia).
Additional symptoms may include:
fascination with visual patterns
rigid behavioural routines — some children may develop entrenched routines of behaviour, such as watching a DVD repetitively from start to finish and may suffer a severe temper tantrum if interrupted
unawareness of pain and injuries.
While most children on the autism spectrum will eat quite healthily, some may have strong food dislikes or will insist on being fed in particular ways. Food dislikes may be based on colour or texture rather than taste and some children will insist on food being separate on their plate.
In addition, it is also common for children on the autism spectrum to have symptoms or aspects of other conditions such as:
attention deficit hyperactivity disorder (ADHD)
dyspraxia (developmental co-ordination disorder)
anxiety and depression.
Some children may have accompanying learning disabilities.
Many children with mild to moderate ASD may find their condition improves as they grow older, and attending school may encourage their social interaction and language skills. However, others may find the school environment difficult to cope with and may exhibit disruptive behaviour in response. Those with more severe symptoms may find these becoming more evident.
Causes and diagnosis
The causes of ASD are unknown but researchers believe that genetic and environmental factors are involved. These are sometimes referred to as “primary ASD” or idiopathic ASD. In some cases, underlying conditions may cause the symptoms and these are referred to as “secondary” ASD.
It is believed that 90% of cases of ASD are primary and 10% secondary.
Getting a diagnosis is important as it helps the parents of a child with ASD to get the right help and support.
In many cases, the early signs and symptoms of ASD are recognised in children at around the age of two, often by parents or health professionals concerned about their development.
Where appropriate the GP will refer a child causing concern to a healthcare professional or multi-agency team who specialise in diagnosing ASD. Such teams may include consultant paediatricians, psychologists, psychiatrists or therapists, such as speech and language therapists.
The team will take a detailed history and carry out a number of interviews where a child’s skills and behaviour can be assessed. Information required by the team may include details about a child’s development at nursery, and about their interactions with other children.
The National Institute for Health and Care Excellence (NICE) publish a clinical guideline, Autism Spectrum Disorder in Under 19s: Recognition, Referral and Diagnosis [CG128].
A positive diagnosis of ASD may distress or shock some parents or carers and they may struggle to come to terms with it. It is important at this stage that they are provided with adequate support and help and are given the opportunity to talk issues through and obtain advice.
The National Autistic Society (NAS) is a good source of such support and has an excellent range of resources and advice on its website.
There is no cure for ASD. However, a range of specialist education and behavioural interventions are available which can improve the skills of children with autism. Most focus on improving a child’s communication or social interaction skills.
Funding for programmes vary from one area to another and access to adequate treatment or support can be a source of great frustration to parents.
Advice on what funding is available and how to request it is available from the NAS. The NAS also provide support and advice to parents on strategies and approaches they can adopt to help their child’s development.
Occasionally medication may be prescribed to treat symptoms such as repetitive or aggressive behaviours. This can include the use of antidepressants known as serotonin re-uptake inhibitors, or SSRIs, but these are rarely used for children.
Complementary or alternative treatments include special diets, but there is uncertainty about their effectiveness.
Early years provision
Local authorities have a responsibility to ensure appropriate educational arrangements for individual children with special educational needs and this must include children on the autism spectrum.
Each area will have a special educational needs and disability strategy which sets out how local authorities, schools and maintained nursery schools will implement their statutory requirements. Guidance is provided in the Special Educational Needs and Disability Code of Practice: 0 to 25 Years, published by the Department for Education in January 2015. The local strategy will reflect the key themes of national policy including early intervention, embedding inclusive practice, raising expectations and achievements, and working in partnership.
Early years providers should ensure that they have appropriate policies in place to comply with the Early Years Foundation Stage (EYFS) statutory framework.
The EYFS is based on principles of inclusion which means that early years providers should oppose discrimination and prejudice and welcome all families and children.
Section 3.67 of the EYFS states that providers must have arrangements in place to support children with SEN or disabilities. The guidance states that local authority maintained nursery schools must identify a member of staff to act as Special Educational Needs Co-ordinator (SENCO) and that other providers are also expected to identify a SENCO.
It is vital that a provision has a clearly written policy which describes how it aims to identify children who may be having difficulties, support children with ASD and promote inclusion.
The policy should cover:
identification and assessment
levels of provision
partnership with external agencies
The SENCO should be trained to provide support to other staff and to support children by agreeing plans with parents and carers, setting targets and monitoring progress.
Early years are a crucial time for children on the autism spectrum and what parents, carers, teachers and others who work with young children do in the early years has a great impact on a child’s future. Early intervention in the areas of social understanding, language and communication are key.
Working with children on the autism spectrum
With support from outside professionals, early years providers should develop their own strategy for supporting children with autism, in line with the EYFS guidance, and this strategy should be shared with parents.
Plans for supporting children with ASD will usually be developed by the SENCO and by other practitioners skilled in working with children on the autism spectrum. The plans should be shared with all staff who should be offered any required training, supervision and support.
The approach should be informed by the NICE guideline [CG170] Autism Spectrum Disorder in Under 19s: Support and Management, published in August 2013. This lists general principals of care, as well as interventions for challenging behaviours and interventions that should not be used. Specialist guidance, training and support is available from charities such as the NAS and the Autism Education Trust (AET).
Children with autism benefit from early years services that are well-structured, task-orientated and have clear goals. It is beneficial to keep instructions clear, simple and direct to emphasise routine and structure.
A well-planned early years environment which is based upon the principles of the EYFS will go a long way towards meeting the needs of children with autism. Planning should start from the child’s interests, should be agreed in partnership with parents and activities should be personalised to meet individual needs.
Each child with ASD should have an individualised plan of care agreed with their parents or carers. Children with ASD will need additional support to develop an understanding of the needs, views and feelings of others and to form good relationships with adults and make friends with peers. They will need help to interact effectively with others, take turns in conversation, understand jokes and idioms, make up their own stories and predict what might happen next in a story. Basic numeracy can be a relative strength for some children on the autism spectrum but others will need help. They may need encouragement to try out new things and all necessary support should be provided to enable them to express their thoughts and feelings through creative activities.
As with all children, for those with autism it is important that each child’s unique strengths are recognised alongside their areas of need. Even within an area of difficulty, it should always be possible to identify relative strengths.
Most children on the autism spectrum should make good progress with the right support. However, some will need additional support from specialist services such as speech and language therapy and specialist teachers.
The NAS is the leading UK charity to support people with autism and their families. It provides specific online advice for teaching young children on the autism spectrum available at www.autism.org.uk.
The NAS runs a national helpline available on 0808 800 4104.
Specialist information, training and support can also be obtained from the Autism Education Trust (AET) who publish an Early Years Autism Competency Framework to help staff in working with children with ASD.
The framework and details of training are available at www.aettraininghubs.org.uk.