Autism Spectrum Disorder (ASD)

A Clear Practical Approach for Parents

Dr. Grossmann has provided this ASD section as a clear and practical resource for patients and their
families who live with ASD:
Please use the links below to access the various pages of the ASD guide written by Dr. Rami
Grossmann.
1.

What is ASD (Autism Spectrum Disorder)?

2.

How is ASD diagnosed?

3.

The DSMV V criteria for ASD

4.

What is PDD and Asperger's disorder?

5.

How does a typical child with ASD present?

6.

The ASD assessment scale/screening questionnaire

7.

Who should be evaluated for ASD?

8.

What are the causes of ASD?

9.

Laboratory testing guidelines

10. What is the best treatment for ASD?

11. Behavioral modification
12. Prognosis (long term outcome) of ASD
13. Differential diagnosis for ASD
14. ASD and the educational (school) system
15. Associations related to ASD

1. What is ASD (Autism Spectrum Disorder)?

ASD or autism spectrum disorder is a behavioral disorder of speech, communication, social interaction,
and repetitive type compulsive behavior. There are three levels of ASD recognized by the DSMV
(Diagnostic and Statistical Manual, 5th edition). The three levels of severity for ASD include:

Level 1: Requiring Support: Problems with inflexibility, poor organization, planning,

switching between activities, which impair independence. Poor social skills, difficulty in
initiating interactions, attempts to make friends are odd and unsuccessful.

Level 2: Requiring Substantial Support: Marked difficulties in verbal and nonverbal

social communication skills. Markedly odd, restricted repetitive behaviors, noticeable
difficulties changing activities or focus.

Level 3: Requiring Very Substantial Support: Severe difficulties in verbal and nonverbal
communication. Very limited speech, odd, repetitive behavior; many express their basic
needs only.

2. How is ASD or autism diagnosed?

The diagnosis of ASD is clinical, meaning "what you see is what you've got." One needs to
meet specific diagnostic criteria for ASD, but the general requirements are that one must have
symptoms that belong to the three main areas of impairments:
o

Speech and communication impairment

Social interaction difficulties

Repetitive stereotype behaviors (unusual impulsive and ritualistic mannerisms)

These symptoms coupled with a severe impairment in speech, social skills, or repetitive
stereotyped behavior qualifies one for ASD. The three levels of severity depend on how much
support each individual requires.
At times, especially when diagnosed early, it may be difficult to predict what the final outcome
will be. Even though ASD is a lifelong disorder, some children will do better than others and a
small proportion may "outgrow" some of the difficulties. Subtle changes, however, persist
universally, even in the best of situations throughout life, and involve mostly social interaction
skills and some obsessive-compulsive behaviors.
A simplified way of understanding the diagnosis of ASD is looking at the ASD assessment scale
questionnaire. In order to qualify for an ASD diagnosis, one needs to have some behavioral
features from each one of the three subgroups listed. This, of course, must be associated with
a severe speech, social, or repetitive behavior impairment. A more comprehensive
understanding of the condition and its diagnostic levels is provided by the DSM V criteria for
ASD.
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3. The DSM V criteria for Autism Spectrum Disorder (ASD)

The full diagnostic criteria for the pervasive developmental disorders are outlined below. As
mentioned above, the diagnostic criteria for the autistic (ASD) disorders are defined by the
DSM IV criteria.

Persistent deficits in social communication and social interaction across multiple

contexts, as manifested currently or in history by (examples are illustrative, not
exhaustive):
1.

Deficits in social emotional reciprocity, ranging, for example, from

abnormal social approach and failure of normal back-and-forth conversation to
reduced sharing of interests, emotions, or affect, to failure to initiate or
respond to social interaction.

2.

Deficits in nonverbal communicative behaviors used for social interactions,

ranging, for example, from poorly integrated verbal and nonverbal
communication to abnormalities in eye contact and body language or deficit in
understanding the use of gestures to a total lack of facial expressions and
nonverbal communication.

3.

Deficits in developing, maintaining, and understanding relationships,

ranging, for example, from difficulties adjusting behaviors to suit various social
contexts to difficulties in sharing, imaginative play or making friends, to the
absence of interest in peers.

Restricted, repetitive patterns of behavior, interest, or activities, as manifested by at

least two of the following, currently or by history (examples are illustrative, not
exhaustive)
1.

Stereotyped or repetitive motor movements, use of objects, or speech (e.g.,

simple motor stereotypies, lining up toys, flipping objects, echolalia,
idiosyncratic phrases)

2.

Insistence on sameness, inflexible adherence to routines, or ritualistic

patterns of verbal or nonverbal behavior (e.g., extreme distress at small
changes, difficulties with transitions, rigid thinking patterns, greeting rituals,
need to take same route or eat same food every day).

3.

Highly restricted, fixated interests that are abnormal in intensity or focus

(e.g., strong attachment to, or preoccupation with unusual objects, excessively
circumscribed or preservative interests).

4.

Hyper- or hypoactivity to sensory input, or unusual interest in sensory

aspects of the environment (e.g., apparent indifference to pain/temperature,
adverse response to specific sounds or textures, excessive smelling or
touching of objects, visual fascination with lights or movements)

Symptoms must be present in the early developmental period (but may not be fully
manifested until social demands exceed limited capacities, or be masked by learned
strategies in late life).

Symptoms cause clinically significant impairment in social, occupational, or other

important areas of current functioning.

These disturbances are not better explained by intellectual disability (intellectual

development or disorder) or global developmental delay. Intellectual disability and
Autism Spectrum Disorder frequently co-occur; to make a comorbid diagnosis of ASD
and intellectual disability social communication should be below that expected for the
general developmental level.

Note: Individuals with well-established DSM IV criteria or Pervasive Developmental Disorder

(PDD) should be given the diagnosis of ASD. Individuals with marked deficits in social
communication who do not meet criteria for ASD should be evaluated for social (pragmatic)
communication disorder.
Specify if:
o

With or without intellectual impairment

With or without language impairment

Associated with a known medical or genetic condition

Associated with other neurodevelopmental, mental, or behavioral disorders with

catatonia

There are no subtypes of ASD. The distinction is based on the severity of presentation and the
degree of support required by each individual with ASD. *Level 1: requiring support, *level 2:
substantial support, *level 3: very substation support
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4. What is PDD and Aspergers disorder?

PDD and Aspergers disorder are old terms, belonging to the previous diagnostic (DSM IV)
criteria. There are a total of five different PDDs, explained below.
o

Childhood autism

Asperger's syndrome

Childhood disintegrative disorder

Rett's disease

PDD NOS or Autism Spectrum Disorder not otherwise specified

These terms are no longer in use, as they belong to the previous (DMS IV) criteria, but you
may still hear some professionals use these when talking about a child diagnosed with Autistic
disorder prior to 2013.
A. Childhood autism
Always presents before 36 months of age, these children may have some speech
developmental and social interactive regression, usually around 18 months of age. The
diagnosis of childhood autism must meet the specific DMS IV criteria and will therefore present
with poor eye contact, pervasive ignoring, language delay, and other features. Per definition,
these children will have a severe impairment in speech, communication, or social interaction.
Many of them will be completely non-verbal and "in their own world," with lifelong, severe
impairment.
B. Asperger's syndrome

These are kids with a form of autism that affects language less, yet there are difficulties with
appropriate speech and communicative development. Mostly, however, these children have
social interaction difficulties and impairments related to a restricted, repetitive, stereotype
behavior. These kids may have very high IQ's, may do very well academically, have a superior
memory for "unimportant" details, such as the birth dates of all baseball players, some
historical or geographical trivia, yet they lack the skills to care for themselves and live
independently. These individuals may talk repetitively about a certain topic without
understanding that it may be boring to others. The "amount" of memory of these individuals is
incredible and one may expect different degrees of impairments with Asperger's syndrome.
This may involve more or less memory and more or less social communicative impairment
with regards to being able to live independently. As long as a child or individual seems
"different" or "odd" and has a thought process that doesn't fit the way everyone else thinks,
yet shows some of the required autistic characteristics, Asperger's syndrome should be
considered. Many people with this condition remain undiagnosed because of their ability to
compensate with their memory or excellent academic abilities, yet they are considered by
others to be "socially inept," "weird," "nerds," "bizarre," "eccentric," etc.
A typical example of a child with Asperger's syndrome would be that of a child who has some
odd behaviors, poor eye contact, "sluggish" social interaction abilities, and an extreme interest
in a central topic such as a washing machine. The child likes to sit and watch the washing
machine door rotate, knows everything about it including its operative and professional
manual and may spend hours perseverating about it. Such a child when he has a play date,
may try to involve his "friend" in his most exciting interest (the washing machine) without
realizing how boring it is to others and that will be the end of the play dates forever. This
pattern may present itself in different degrees and circumstances, but the prinicipal is the
same: the lack of the ability to understand how other people perceive what you do, say, or
express with body language and facial expressions.
C. Childhood disintegrative disorder
These are kids who develop normally for the first 3 years of life. Later they seem to regress
and develop some autistic features associated with a severe functional impairment. These
children must be thoroughly evaluated for the possibility of the development of seizures,
affecting the speech areas of the brain, or Landau Kleffner syndrome (acquired epileptiform
aphrasia), where seizure activity "robs" the brain from previously acquired speech.
D. Rett's disease
This affects only girls. These are girls who develop normally until 6 months of age and regress.
Their regression is associated with microcephaly (small head). The head size seems to stop
growing from 6 months and on, from the time of the observed regression. Recently a specific
chromosomal marker (MEC-P-2) has been associated with this disorder and is now
commercially available in some laboratories.
E. PDD NOS
PDD NOS will present similarly to the kids who have autism, but will have a lesser degree of a
severe impairment. These kids are more likely to be verbal and have some degree of verbal or
non-verbal effective communication, yet they must have the autistic features (as per the DSM
IV criteria) and a severe impairment in social interaction, communication, or repetitive
stereotype behavior. This term is reserved for children with a severe impairment who do not
fully qualify for any other autistic diagnosis, due to age of onset or combination of autistic
features.
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5. How does a typical child with ASD present?

Most kids with ASD simply present with a language delay. Some never acquire language, but
most will have a slight regression, losing the ability to say a few words that they've already
learned. This may occur at around 18 months of age. Most parents will report no difficulties
prior to this period, but some may observe a "different interactive," eye contact or
socialization impairment, lack of pleasure with regard to being touched, or other unusual
behavior from as early as 1 to 3 months of age, in extreme situations.
Typically, kids with ASD will not get diagnosed initially. The statistics indicate that only about
10% of kids with autistic disorders get diagnosed following the initial complaint of the parents
that "something is wrong" with their child.
At the onset of symptoms, when the child regresses, several difficulties may appear. There is
loss of eye contact, the child drifts into his own world, may sit quietly for prolonged periods of
time, and develops pervasive ignoring of other people. This means that he may be called
several times, even very loudly, and ignore the calling as if he is deaf, yet when he hears even
the slightest sound of something he likes, such as song from a favorite video, he runs to it
immediately. Some of the kids develop hand flapping, toe walking, and severe temper
tantrums, especially when required to change from a favorite activity to some other activity.
Arranging toys in rows, spinning themselves or objects, or showing fascination in spinning
objects, straight lines, or trains is a common behavior.
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Language delay or lack of language may be expected. Language may be replaced by some
unusual, infantile squeals or shrieking, and repetitive, unintelligible gibberish may occur. Once
language has developed, repeating heard words is common. For instance, instead of answering
the question "What's your name?" a child will repeat the question and say, "What's your
name?" Other unusual use of language may be present including perseveration into a certain
sentence or television commercial that is repetitively said out of context and without having
any communicative purpose. Some children are becoming interested in numbers or letters and
some may even read fluently from a very young age of 2-4 without being able to talk
communicatively or understand what they read. A savant ability or restricted skill, superior to
age group, such as math, reading, or drawing skills in a toddler, may develop.
Many of the children who have ASD may be also hyperactive. Some may be very difficult to
control due to their hyperactivity and temper tantrums, and some are "very easy" because
they may sit for hours without requiring special attention or stimulation from their caregivers.
Some children in ASD may be so hyperactive that their hyperactivity overwhelms the clinical
picture therefore resulting in a misdiagnosis as AD/HD, overlooking some significant difficulties
related to the ASD aspect of the condition. In a situation where there is a coexistence of ASD
and AD/HD symptoms, the combined ASD and AD/HD diagnosis may be considered. Unlike the
DSM IV, the DSM V permits the coexistence of both conditions in the same individual.
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At an early point, many parents deny the problem and since they are told that language will
develop later, that "some kids are late bloomers," the initial concerns become suppressed. A
typical problem that develops at this point is that parents give in to temper tantrums. This in
turn develops a "pathologic" situation, where instead of the parents teaching their abnormal
children normal socially accepted behavior, the entire family "learns" the abnormal behavior
from their affected children. This causes the child to lose his chance of being appropriately
directed into socially accepted behavior from early on, as should be done.

As a rule, parents who change their normal behavior in order to accommodate their children's
abnormal behavior are doing a severe disservice to their children and to themselves. The
correct approach must include a firm, strict discipline to correct all their child's abnormal
autistic behavior (see behavior modification). Typical mistakes in this regard include letting the
kids run around with food because they refuse to sit by the table, allowing their children to
carry an exaggerated variety of objects or toys everywhere they go in order to pacify them,
letting their kids get away with holding their bottles or pacifiers, or refusal to eat certain
consistencies of foods in order to keep the peace and prevent temper tantrums.
In the long run, however, tantrums are unavoidable because there is a point where the
parents cannot keep up with their children's unreasonable requirements, and if the response of
the parents to the unreasonable request is not fast enough or not complete enough, the
tantrum will occur. The best way to stop the tantrums right from the onset is to help the child
adjust to the requirements of society. In the long and short run, it is wiser and more effective
to change the child in order for him/her to fit the world, rather than change the world (or
home environment) to fit the childs abnormal behaviors. The wrong approach will lead to
immediate, extreme clashes between the child and school once he/she leaves the home.
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The presentation of children with ASD, as described above, may be variable and may include
different types of unusual behavior as listed on the ASD assessment scale questionnaire. Most
commonly, the diagnosis will be a mild form of ASD. Children with a more severe form may,
however, present earlier.
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6. The ASD assessment scale/screening questionnaire

The questionnaire available below is an experimental screening tool based on the DSM-V
criteria for ASD.
To take the ASD questionnaire, use the link below and open the separate page for the
questionnaire. There are links on the page that define the grading and scoring to help you
decide on the correct answers. After answering all questions, you click on "Score" at the end
to reveal your score.
Once you have answered all questions and the score appears, you should print the page and
bring the results to the physician appointment as one tool for discussing symptoms. The score
is NOT indicative of a definitive diagnosis by itself.
o

The ASD Assessment Scale/ Screening Questionnaire

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7. Who should be evaluated for ASD?

In every child who has any type of speech delay, the question of ASD must arise. Recent
recommendations by the American Academy of Neurology (AAN) specify some general early
guidelines in that regard. These include:
o

No babbling by 12 months

No pointing or waving bye-bye by 1 year

No single words by 16 months

No spontaneous 2-word sentences (for communication, not repetition) by 2 years

Any loss of acquired speech or communication skills at any age

Several speech developmental screening and rating scales are suggested by the AAN but the
above guidelines cover the vast majority of children that require a more specific evaluation.

8. What are the causes of ASD?

The causes for ASD are most likely genetic. In most kids who present with a mild form of ASD,
despite a very extensive workup that may include blood test, urine tests, imaging studies, and
other tests, everything comes back normal. The general consensus is that ASD is a genetic
disorder that sometimes can't be identified in current genetic testing. This may never become
specifically identified because ASD may represent a variety of genetic abnormalities.
Identified causes for ASD include several chromosomal abnormalities involving different
"genetic sites." Fragile-x syndrome involves the x chromosome, Angelman's syndrome
involves chromosome 15, and many other chromosomal abnormalities may present with
"ASD." Other disorders such as Touberouse sclerosis, a disorder causing skin and brain
abnormalities and frequent severe epileptic seizures (chromosome 9 and 16) may present with
"ASD" also. Some "metabolic disorders" such as PKU (phenylketonuria), where a substance
(phenylalanine) accumulates in the brain, and other disorders of metabolism may present with
ASD.
Another important condition that may cause ASD is a form of a seizure disorder or Laundau
Kleffner syndrome. This disorder, also known as acquired epileptiform aphasia, is a disorder in
which non convulsive seizures, which occur mainly at night, may rob a child from previously
acquired speech. This is an important diagnosis, because some treatments may effectively
help it.
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9. Laboratory testing, medical consensus guidelines

According to the recent recommendation of the American Academy of Neurology, almost no
tests at all are required for most children with mild ASD. Specific testing should be considered
according to the specific finding on history or examination.
Hearing Test
A hearing test is indicated for all children with any type of speech delay or evoked potential
testing (brainstem auditory evoked responses, BAER) for hearing evaluation. Specific
developmental testing should also be performed, including an IQ test if indicated.
Lead Level Test
Lead level should be checked mostly in children who have PICA, where "everything goes to the
mouth."
Genetic Testing
A high-resolution chromosomal analysis is suggested in these children where indicated, mostly
to detect Fragile-x, the Prader Willi, or Angelman's syndromes. This is mostly performed when
the child looks dysmorphic (unusual), or the head size is small (microcephally).

Blood Metabolic Testing

Not routinely suggested and should be considered when a regressive pattern is suspected or
other clinical evidence leads one to suspect such a disorder.
EEG
An EEG is a brain wave analysis. It is suggested in those who have a regressive pattern to rule
out Laundau Kleffner syndrome or other forms of seizures.
Imaging (Head CT or MRI)
Not routinely suggested, imaging should be considered if Touberouse sclerosis is suspected or
other structural brain abnormalities are considered.
Tests Specifically Not Suggested on a Routine Basis
The following tests are not suggested on a routine basis: hair analysis, celiac antibodies,
allergy testing and fungal immunologic, neurochemical micronutrients, and vitamin testing.
Also stool, urine analysis, thyroid, lactic acid, or other sophisticated specific metabolic testing
maybe be avoided.
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10. What is the best treatment for ASD?

The best treatment for ASD must combine several disciplines - behavioral, developmental,
academic, and medications. The treatment must be customized to each individual child's
requirements and must follow the general principle of trying to achieve the best possible
functional ability using the available resources as needed.
Behavioral modification may be very helpful. Children with ASD may assume a wild
behavior that if not corrected may lead to severe, life threatening behaviors that may require
extreme measures. Early strict behavioral modifications may prevent future use of medications
and institutionalization.
Parents must remember! If the family changes their normal behavior and assumes abnormal
routines (in order to accommodate to the child's abnormal behaviors and prevent his temper
tantrum), instead of the family teaching the child normal behavior, the entire family becomes
behaviorally disrupted and the child with ASD loses his chance to learn normal, socially
accepted behavior.
Behavioral modification is effective if strictly applied and should be directed at correcting
everything that is abnormal in the childs behavior, and that is potentially correctable. (See
next section on behavioral modification.) Other behavioral and developmental treatment
disciplines include ABA, speech therapy, occupational therapy, and special education.
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Occasionally, physical therapy may be helpful in some kids with ASD who also suffer from
hypotonia (low muscle tone) or other physical impairments.
Medications for ASD are utilized as required, directed at specific treatment goals. One must
take into consideration the fact that children with ASD may react unexpectedly and differently
than expected to any medications used. Kids who also suffer from hyperactivity (a common
combination) may benefit from stimulants (Adderall, Ritalin, Dexedrine) as indicated in our
AD/HD section of the site. These may reduce hyperactivity and improve the attention span in
children with ASD as well.

Children who have a lot of obsessive-compulsive symptoms (OCD) may benefit from SSRI
(selective serotonin reuptake inhibitors). Available in the US in liquid form are Prozac, Paxil,
and Celexa. Others include Lurox and Zoloft. These are antidepressants that also have a
benefit in treating OCD by increasing serotonin concentration in the brain. These medications
were studied and have shown a statistically significant improvement in some autistic
symptoms compared to placebo. Some children, however, become more restless when
exposed to the SSRI's. Still, these may be considered some of the safest, most beneficial
medications to try.
Major tranquilizers are used in children that have very erratic, disruptive, dangerous
behaviors. If prescribed at night, this may help with sleeping difficulties. These medications
include Risperidal (liquid form), Zyprexa, Abilify, Melleril, Haldol, and Seroquel. One must use
these with caution and look out for some side effects. Weight gain is a very common side
effect. Somnolence or drowsiness may also occur. Rare long-term side effects include tardive
dyskinesia, a movement disorder involving the oral muscles, tongue, and extremities. This
may be irreversible. Changes in liver enzyme counts have also been reported.
Other medications, including some traditional antidepressants, anti-anxiety medications, and
combinations of some anticonvulsants have also been used for ASD but less commonly.
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Other different treatments such as auditory integration training, vitamin and mineral
treatments, and secretin injections have been anecdotally reported to be helpful, yet were
never proven to make a difference and are not recommended by the American Academy of
Neurology; therefore their use is controversial, and not recommended. One must remember
that some kids with ASD improve "spontaneously" without any apparent treatment. This
makes it difficult to decide whether the improvement was related to a treatment or occurred
spontaneously, unless studies are done in a controlled fashion and compared to placebo.
Unfortunately, none of the controversial treatments wer ever proven effective in a scientific
fashion.
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11. Behavioral modification

Behavioral modification program for a child with ASD:
This behavioral modification program is based on training the child to behave in a more
appropriate and socially accepted manner. This should consist of an immediate correction of
any aberrant behavior, utilizing a special holding technique to overcome temper tantrums.
Many of the most difficult behaviors, if dealt with early, may become controlled, or if
neglected, may lead to a wild, impulsive, uncontrollable behavior that may require
institutionalization. In many families of children with ASD, instead of the children being taught
normal, socially accepted behavior, the entire family learns abnormal behaviors from the kids
in the process of trying to accommodate them to prevent the temper tantrums. This is why
controlling the tantrums is so important. Accommodating these kids by giving in to the
abnormal behaviors only delays the tantrums and makes the abnormal behaviors the accepted
standard for those children with ASD.
o

A structured daily routine is important. The child will perform best under familiar
conditions, including location and activities. Later, as the situation improves, the rigid
routine may be gradually modified, as tolerated.
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Temper tantrum control: Controlling temper tantrums is of extreme importance.

The holding technique, as demonstrated during the office visit, requires a gentle, yet
firm hold of the child, with the back to the parent's chest; the child's legs should be
held between the parent's legs. During the holding time, the parent must try to
communicate with the child, calm him/her, yet not give in to the behavior that led to
the tantrum. This procedure is not a form of punishment. It is devised to protect the
child and others from the erratic behaviors. It must be done gently, not to hurt the
child, yet firmly to get a clear unequivocal message through. It definitely is not meant
to be "fun" time and a firm approach is required. Communication must be short, clear,
and firm, expressing the parent's appropriate emotional reaction to the behaviors that
led to the tantrum. The reaction (firmness of communication) must be proportionate to
the severity of the behavior. This will also teach a child whose ability to understand
emotional responses are impaired, how one must react under different circumstances.
The main objective of the holding and the behavioral modification program is to
correct inappropriate behaviors, thus trying to normalize the child's routines and
behavior, including all social interactions as much as possible.
There are three priorities, when it comes to "insisting" with a child over behavioral
issues.
1.

First priority: Temper tantrums and inappropriate behavior that if left

unchanged may potentially become life threatening, such as hitting, throwing
objects, jumping out of high places or windows, running into the street, or
refusing to eat, must be attended to immediately, without compromise.

2.

Second priority: "Sitting skills." Behavior, that if left alone, will make it
impossible for the child to sit in class and, therefore, impossible to attend
school with his/her peers, regardless of his abilities or "baseline IQ." This
consists of teaching sitting skills. This may be accomplished while sitting for
dinner with the rest of the family, sitting in a restaurant or at any family or
social gathering that require sitting skills.

3.

Third priority: Dealing with the "repetitive ritualistic habits. Unusual

"bizarre" behaviors, that may result in social isolation or difficulties, if left
unchanged. Such are inappropriate play habits, pervasive repetition of
activities, self-stimulatory behavior, hand flapping, persevering into strict
interests or production of unusual sounds. This may be done with a simple firm
"stop!" command, and by directing the attention to more appropriate
behaviors.
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The holding technique is very important and constitutes the frame structure for the
behavioral modification program. The holding should be done with compassion, not
trying to hurt the child, but helping him/her to adjust to a difficult situation. This is not
a form of punishment. Only one parent should communicate with a child while being
held. One parent holding, while the other is smiling and trying to console the child, will
cause confusion and the wrong message to come through.
The behavioral modification teaches the child to acquire a more socially acceptable
behavior, thus giving him/her a better starting point, to enter life's social
requirements, compared to a child who still remains with all the attended social,
behavioral difficulties associated with ASD.
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Communication: Must be short, clear, loud (not yelling). Many children with ASD
have auditory integration difficulties. Talking to them excessively will not be registered
and may sound to them like gibberish. Therefore, communication must be very simple
and to the point, leaving time between words to integrate the information. Eye contact
must be worked on. As the child improves, communication may become more fluent
and elaborate.
Never smile or regard inappropriate behavior as cute or funny. Some behaviors as
pulling a parent to different locations must be discouraged. Facial expressions by the
parents must be appropriate and sometimes exaggerated to teach the socially
appropriate way of expressing emotions. Proper attempts by the child to communicate
must be encouraged and pursued.

Individualization of care: The behaviors of individuals with ASD may differ in many
aspects. Each child has his own strengths and weaknesses. A good behavioral
modification must be customized to each child's specific needs. The principle of
correcting inappropriate behavior, however, applies to all.
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Placement and education: The most regular, highest functioning environment,

including a regular educational system, should be attempted whenever possible. This,
with independent supplementation of all the other needs, including speech therapy,
occupational therapy, and physical therapy, if needed, will result in the most favorable
outcome. When a regular educational system is unrealistic, each community may offer
different options. The parents should individually and personally check these options.
Once in the program, I do encourage parents to come in and observe first hand the
quality of services provided, and how the child fits in. You have to give it some time,
but remember, be a strong advocate for your child. There is no program that fits
exactly the individual needs of every child with ASD, therefore sometimes you may
have to use your creativity, based on the knowledge of your child, to obtain the best
solution. Rarely, you may have to actively pull your child out of a program if he/she
does not fit and seems to regress, and find a better alternative. Parents must,
however, be realistic about the childs potential.

Emotional aspects: No one can clearly determine the final outcome of a child with
ASD. Do not give in. Have realistic expectations yet try to push him/her as much as
possible. Try to demand from your child to behave like any other regular child and
regard them as such. Do not let the child "get away with things" because he/she is
autistic. If your expectations are set too low, it may impair the final outcome. On the
other hand, when it is clear that a child cannot perform a certain task, know where to
stop. The right balance may be sometimes difficult to determine.
The "A" word and the social stigma: The public and some professionals,
unfortunately, lack education when it comes to ASD. Do not deny the problem, try to
educate yourself and deal with the specific difficulties. On the other hand, keep the
diagnosis private, if possible, to prevent expectations from educators and the public in
a way that may eventually affect your attitude and opinion as well. This applies to mild
cases of ASD.
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Other treatment options: Different modalities are available. Some are controversial,
some clearly ineffective. There are no studies that unequivocally demonstrate
beneficial results from vitamin or diet therapy, but there are some anecdotal reports

falsely supporting many modalities. Contrary to this, there are reports of improvement
without any "therapeutic" intervention.
Modalities that can be considered should be free of side effects. Auditory and sensory
integration training, when done properly, benefits certain children with ASD. Other
modalities are discussed in the ASD package. To receive a package, you may call
1.800.3AUTISM or link to the Autism Society of America website.
o

Medical treatment: Medications should be directed at specific goals. Stimulants

(Ritalin, Dexedrine, Adderall ). SSRI's (Prozac, Zoloft Paxil and Luvox). At times,
neuroleptics are used (Mellaril, Risperidal, Zyprexa) or tricyclics (Tofranil) may be
helpful. Other medication options can be discussed with an experienced physician as
new treatments may become available.
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12. Prognosis (long term outcome) of ASD

The long-term outcome for ASD is variable. It is difficult to determine during the first visit of a
1 to 2-year-old child what his future ability will be. It is however clear that this is a life long
disorder that will leave its impact one way or another on the individual's life. The most
important prognostic factor is the I.Q. ability of the child. Also, the degree of social interaction
impairment and lack of appropriate communication early on correlates with the severity of the
outcome. Early intervention that includes behavioral modification and speech therapy may also
change the outcome positively. The most accurate predictor of outcome, however, is the
progression over a period of about 1 year from early diagnosis. Those with mild ASD and few
autistic features may do remarkably well. Some other factors, such as associated comorbid
disorders like depression, anxiety, and severe OCD may have a significant impact on outcome.

13. Differential diagnosis for ASD

Some conditions may be confusingly similar to ASD and one must be careful when making a
final determination about a child's disorder and its management. Any condition that may be
associated with language delay, especially those that are treatable, must be considered.
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Hearing loss: Every child with a language delay must have a hearing test. A child
with a hearing impairment will not have the autistic features as mentioned by the DSM
V criteria, but may present with "pervasive ignoring," production of unusual sounds,
"poor eye contact" because he can't coordinate his eyes to the direction of the sound,
some temper tantrums due to the frustration caused by the lack of the ability to
express his needs, and some other features. These kids however, will never fully
qualify for the full diagnostic criteria of the ASD and this is a reason why a diagnosis
can't be based on only a part of the diagnostic requirements. A patient with deafness
who is appropriately treated will make a rapid recovery of his lost language if treated
early. For this reason, a hearing test is always important to obtain in a child with a
speech delay (even if the parents think he can hear) because the hearing loss may be
partial or selective to different frequencies. Many children with ASD will have some
pervasive ignoring of other people that may render a conventional hearing test
ineffective. These children will benefit from having a BAER (Brainstem Auditory Evoked
Response) where electrodes register the brain's response to sound delivered by
earphones to the child. In most situations, this test will have to be performed under
sedation.
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Landau Kleffner Syndrome or acquired epileptiform aphasia: This is a rare

condition in which children, mostly older than 3 years of age but occasionally younger,
develop seizure activity that includes seizures involving the left hemisphere (the
speech areas) and nocturnal status epileptics. These kids commonly, but not always,
present with convulsive seizures and have associated autistic regression and loss of
acquired speech. Because of that, it is recommended to obtain an EEG (sleep deprived
or 24 hour recording) on those autistic children who have a history of loss of acquired
speech and behavioral regression. This condition can be successfully treated with antiepileptic drugs and ACTH.
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Mental retardation: Another condition that may mimic ASD is mental retardation. It
may present with speech delay and if severe enough, self-stimulatory behaviors and
other "autistic characteristics" may be associated.

Childhood schizophrenia: This is rare and may mimic ASD. This condition usually
develops after 5 years of age is associated with a higher I.Q. score (more than 70)
than what is found with ASD.
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14. ASD and the educational (school) system

The school system is not always geared to deal with the special needs and apply the special
modalities required in the management of an autistic child or children with ASD. That includes
lack of specific experience, the unavailability of ABA or proper behavioral modification
programs.
In many circumstances, children with ASD are placed with a bulk of kids who have a speech
delay for other reasons including mental retardation or hearing loss. Services may be
unavailable in some areas. In our area, however, more and more institutions are specifically
geared to deal with ASD and parents must educate themselves with regards to where a child
may be placed. In some circumstances, improvements may be observed due to an excellent
interaction between a child and a therapist regardless of the specialization of the school. My
general guideline is to try to find the highest functioning environment into which the child may
fit and enhance his abilities with extra speech therapy and, of course, behavior modification.
In the future, as more awareness, resources, and knowledge are directed toward ASD, more
choices and management modalities will become available.
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15. Associations related to ASD (Links)

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Autism Society of America

(800)-3AUTISM, extension 150
(301)-657-0881
Fax: (301)-657-0869
The mission of the Autism Society of America is to promote lifelong access and
opportunities for persons within the ASD and their families, to be fully included,
participating members of their communities through advocacy, public awareness,
education, and research related to ASD. Their extensive website provides education for
families, information on local groups and resources and much more.

Center for the Study of Autism

The Center provides information about ASD to parents and professionals, and conducts
research on the efficacy of various therapeutic interventions. The website covers many
topics of interest to parents, educators, and care providers.
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Child Neurology and Developmental Center

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