Childhood autism
Childhood autism is a subtype of pervasive developmental disorder. It is a developmental disorder that occurs in early childhood and is characterized by impaired contact with the outside world (including parents). It is characterized by varying degrees of interpersonal difficulties, narrow interests, and stereotyped behavior. About 3/4 of the children have significant mental retardation, and some of them have some aspects of better ability against a background of general intellectual backwardness. It is more common in boys.
Distribution characteristics
The prevalence of autism in foreign countries is 2/10,000 to 4/10,000, but later, due to improved survey methods, it was found to be up to 10/10,000. In China, the prevalence of autism in childhood is 2.9 per 10,000. There is no national epidemiological data in China, but it is estimated that there are 150,000 children with autism in China. In Japan and Hong Kong and Taiwan, it is also known as autism and pervasive developmental disorder (PDD) is a group of comprehensive mental developmental disorders that begin in infancy and early childhood.
Features.
Abnormal interpersonal and communication patterns
Impaired verbal and nonverbal communication
Limited, stereotyped, and repetitive interests and activities
Onset before the age of 3 years, usually more pronounced by the age of 5 years
Etiology and Pathogenesis
The etiology of the disease is still unknown. Many foreign studies have suggested that genetic, family characteristics, psychosocial, physiological, anatomical, biochemical and other factors may be involved.
1. Genetic factors Studies have found that the rate of homozygosity is higher in monozygotic twins than in dizygotic twins. There are more autistic patients in the families of children with the disease than in general families, indicating that some of the affected children have a genetic predisposition.
Biological factors There are more children with a history of perinatal damage than normal births, including congenital rubella, premature birth, obstructed labor, birth injury, and asphyxia. The number of children with software signs in the nervous system can be 40% to 100%. Epilepsy occurs more frequently in children with autism (10%-15%), and the EEG is mostly abnormal. Some studies have found that more children with autism have enlarged left temporal lobe corners, suggesting that there may be lesions in the middle temporal lobe of the brain.
3. Biochemical factors Dopamine and 5-hydroxytryptamine may be increased in children with autism, but they are not specific.
Family factors Kanner believes that the cause of the disorder may be due to inappropriate parenting methods or a specific form of inheritance in the parents’ personality, or both. Research studies have shown that most parents have a high level of education, parents are more introverted, cold and stubborn towards their children, and families lack warmth.
Clinical manifestations
The disease starts mostly at the age of 2 to 3 years, but there are also cases that start at birth. The main clinical manifestations are as follows.
1. Interpersonal disorders Children with this disorder are particularly lonely, lacking interaction with people and emotional connection, such as newborns not being held close to their mothers when they are picked up; no difference in reaction when they are picked up by relatives or other people at 7~8 months; children are indifferent to the return and departure of their parents and have no attachment; they do not feel fearful of relatives and of living people, and they do not feel fearful when they are with strangers. These children lack eye-to-eye gaze and often avoid looking at each other, and lack emotional communication with people around them.
Children with autism often have a special interest in certain objects, such as blocks, radios, balls, etc., to the extent that they become attached to them. They love these objects and feel satisfied in playing with them. If these objects are taken away, they will cause crying and panic. The affected children rarely participate in the games of other children, but are happy to play alone and often enjoy themselves.
3. Language development disorder is one of the most prominent manifestations of this disorder. Children with the disease generally have a gradual decrease in language, or in severe cases, a complete lack of it. The child’s ability to understand language is low, and abnormal language such as stereotypes, repetition, imitation and misuse of pronouns often appear. The child lacks abstract concepts, and the thought process tends to be obsessive, limited and impoverished, lacking in fantasy and imagination. The child does not use facial expressions, body movements, postures and tones to interact with others.
Children with autism are not obviously dull in appearance, but they are obviously lagging behind in social adaptability and cannot take care of themselves in daily life, and most of them have moderate or severe mental retardation. Very few children with autism may show special ability in music, computer and mechanical memory, and very few children may have insular precociousness or idiosyncratic functions, which is called “idiot scholar”. Some children have seizures.
The child often insists on repeating stereotyped patterns of play and life activities, lacking variation and imagination, such as repeatedly lining up toys; not changing the position of sitting; not changing the place where things are placed; and keeping the order of life content as it is. Stubbornly staying the same as before is one of the important symptoms of autism.
6. Sensory-perceptual impairment The child is unresponsive to auditory and visual stimuli, as if he/she is “blind” or “deaf”. The child does not seem to see people or other characters in the surroundings, and ignores their speech.
Diagnostic criteria
1.CCMD-3 diagnostic criteria for pervasive developmental disorder (F84)
Pervasive developmental disorder refers to a group of comprehensive mental developmental disorders that begin in infancy and early childhood, mainly abnormalities in interpersonal and communication patterns, such as verbal and nonverbal communication disorders, limited, stereotyped, and repetitive interests and activities. Symptoms are often evident by the age of 5 years and may improve slowly later. Most children with mental retardation (which should be diagnosed in parallel). Some cases may be associated with certain somatic disorders, among which infantile spasms, congenital rubella, tuberous sclerosis, intracerebral fat deposition disease, and fragile X chromosome abnormalities are common. However, the diagnosis of this disorder should be based on behavioral disorders, and separate coding is required for concomitant conditions.
2.CCMD-3 diagnostic criteria for childhood autism (F84.0)
It is a subtype of pervasive developmental disorder, mostly seen in boys, which starts in infancy and early childhood, mainly with different degrees of interpersonal disorders, narrow interests and stereotyped behaviors. About 3/4 of the children with this disorder have significant mental retardation, and some of them have better abilities in some aspects against the background of general intellectual backwardness.
(I) Symptom criteria Among the following ①, ② and ③, there are at least 7 items, and at least 2 items in ①, and at least 1 item in each of ② and ③.
(1) There is qualitative impairment in interpersonal communication, at least 2 items.
Lack of interest in group games, loneliness, and inability to empathize with the joy of the group.
Lack of skills to interact with others, unable to establish partnerships with peers in a manner appropriate to their intellectual age, such as only pulling, pushing, or hugging as a way to interact with peers.
Self-indulgence, lack of interaction with the surrounding environment, and lack of appropriate observation and emotional response (including to the presence or absence of parents).
Does not use eye-to-eye gaze, facial expressions, gestures, and postures appropriately to communicate with others.
Does not play games or imitate social games (e.g., does not play house, etc.).
Does not seek sympathy and comfort when unwell or unhappy; does not show concern and comfort for others’ unwellness or unhappiness.
(2) There is a qualitative impairment in verbal communication, mainly in the use of language.
Oral language development is delayed or does not use verbal expression, nor does it communicate with others using gestures, imitation, etc.
Language comprehension is significantly impaired, often not understanding instructions, not expressing their needs and pain, rarely asking questions, and lacking response to others’ words.
Has difficulty learning language, but often has meaningless imitative speech or reactive speech, and applies pronouns confusingly.
Frequent repetition of words unrelated to the environment or occasional strange noises.
Children with verbal abilities are unable to initiate and maintain conversation and respond simply.
Abnormalities in the tone, accent, speed and rhythm of speech, such as lack of inhibition, rise, pause and setback in speech, and stereotyped speech.
(3) Narrow interests and activities are stereotyped and repetitive, insisting on the same environment and lifestyle.
Restricted interests, often focused on one or more patterns, such as a spinning electric fan, fixed music, advertising words, weather forecast, etc.
Hyperactivity, pacing back and forth, running, spinning, etc.
Refusal to change a stereotypical repetitive action or posture, and denial can appear as marked irritability and restlessness.
Excessive attachment to and satisfaction from certain smells, objects, or parts of toys, such as a particular odor, a piece of paper, smooth clothing, the wheels of a car toy, etc.
Compulsive fixation on particular and useless routines or ritualistic actions or activities.
Severity Criteria Impaired social interaction function.
Course Criteria Usually starts within 3 years of age.
Exclusion criteria Exclude Asperger syndrome, Heller syndrome, Rett syndrome, Specific Receptive Language Disorder, and Childhood Schizophrenia.
3. Atypical autism (F84.1)
It refers to a syndrome of pervasive developmental disorder with atypical symptoms (only partially meeting the criteria for autism symptoms) or atypical age of onset (e.g., symptoms appear after 3 years of age), which can be considered for this diagnosis. Atypical autism can occur in children with near-normal intellectual development or severe mental retardation, mostly in boys.
4. Screening for infantile autism
Screening for infantile autism can be performed using the Kirsch Behavior Scale (Table 1).
Table 1 Kirsch Behavior Scale
The CAhs should be at least 30 for children without low intelligence.
More accurate diagnostic instruments can be applied where available.
Differential diagnosis
1. Mental retardation is characterized by low intelligence and adaptive deficits. It is usually kind and relatable, without severe social interaction disorders such as loneliness. Children with severe mental developmental disorders are often accompanied by features such as dullness in appearance, according to which they can be distinguished from autism.
2.Children with schizophrenia The child generally has normal development, normal intelligence and signs of schizophrenia such as emotional and thinking disorders or hallucinatory delusions.
3.Children with attention deficit hyperactivity syndrome The child mainly has hyperactivity and attention deficit disorder as the main manifestation, with normal or basically normal intelligence and no interpersonal communication difficulties.
Treatment overview
Special education and behavioral intervention therapy are mainly adopted.
1.Treatment purpose
(1) Promote the development of normal behavior of the child and train the behavior at the appropriate age.
(2) To correct abnormal behaviors (such as stereotypical movements).
(3) To help families learn how to educate and train children with autism.
2.Special education One-to-one education and training for function can be used, and group training for developing interaction skills can also be used.
(1) Planned special education is very important in order to promote the development of language and social interaction skills of the child. There are more technical methods used in special education, such as image object teaching, gestures, postures, interaction and conversation, games, emotional giving, music and physical therapy, aesthetic work, etc., which should be suitable for the level of cognitive impairment of the affected children and pay attention to individualization of education.
(2) Games have an important role in education, and physicians can also observe and understand children’s condition through games. Games can reflect the inner world of the child and give vent to the repressed emotions, play a psychological diversion, and at the same time have a therapeutic effect.
Behavioral intervention therapy Operant conditioning, i.e., positive reinforcement and abatement or punishment, is often used for children with autism. A reward is given when a good behavior occurs, so that the behavior can be reinforced. When some inappropriate behaviors or actions occur, they are ignored or “punished” to make them subside.
4.Medication
(1) Haloperidol: It can reduce behavioral symptoms, such as irritability, excessive activity and stereotyped movements, and has a good effect on improving loneliness and learning ability. Usually apply 1~2mg/d.
(2) Fenfluramine: It can reduce hyperactivity and stereotyped movements, but should be used with caution in infants and children.
(3) Naltrexone: It can increase language and reduce loneliness and stereotyped movements. The applied dose is 0.5~2mg/(kg?d).
Some drugs that promote the metabolism of brain tissue can also be applied.
The opioid receptor antagonist Naltrexone and high-dose vitamin B6 are under trial observation.
Psychosocial support system
Because of the poor prognosis of the disease, many parents of the affected children are in anger, pain, despair and loneliness, and this state of mind will undoubtedly have a lot of adverse effects on both the affected children and their parents.
In addition, the autism associations that have been established in some provinces and cities in China also play a great role in this regard.
Prognosis
The prognosis of this disease is poor. The prognosis is better if the child with autism has a high IQ (IQ>70) and is able to interact with language at the age of 5-7 years. If the IQ is below 60 and the child still has poor verbal communication at the age of 5, the prognosis is poor and may lead to lifelong disability. About 1/5 of children with autism develop seizures by adolescence.
In conclusion, since the release of the movie “Man in the Rain”, people have become more aware that autism is a serious brain developmental disorder rather than some bizarre behavioral problem, and that it is not a fixed and intractable disease, and that early social and family intervention treatment is crucial.