Autism Still a Puzzle

Within the spectrum of pervasive developmental disorder, the narrower term "autistic disorder" is used to refer to classic autism (see SHA, Sept. ‘97, p. 7). The main symptoms of autism are deficits in socialization, verbal and nonverbal communication, and the range of the child’s interests and activities. Contrary to popular view, children with autism may be affectionate, but on their terms and without the expected joy. Parents of such toddlers may describe them as independent rather than aloof and may be proud of their supposed self-sufficiency. The inordinate shyness, fearfulness, anxiety, or lability of mood of the child with autism may be replaced by detachment or depression in adolescence. Unprovoked aggressiveness, if not dealt with early, may become a major problem and lead to a need for heavy medication or institutionalization.

Although the lack of a drive to communicate or the withholding of speech has a role in all silent children, young children with autism have actual language disorders as well. Comprehension and the communicative use of speech and gesture are always deficient in young children with autism.

Children with autism do not know how to play. They may manipulate or line up toys without apparent awareness of what the toys represent, and they do not engage in pretend play, which in normal children, starts before the age of two. Therefore, the observation of what a preschool child does with representational toys is an efficient way to detect autistic traits.

With regard to cognition, approximately 75% of individuals with autism are mentally retarded, but the neurologic or chemical nature of autistic deficits is unknown. No drug or other treatment cures autism, and many patients do not require medication. However, psychotropic drugs that target specific symptoms may help substantially.

Type of Drug Examples

stimulants methylphenidate, pemoline

noradrenergic agents propranolol, clonidine (patch)

serotonin-reuptake fluoxetine, clomipramine,

inhibitors, sertraline, fluvoxamine

antidepressants

dopamine-receptor haloperidol, thioridazine,

blockers chlorpromazine

anti-anxiety buspirone

opioid antagonists naltrexone

mood stabilizers lithium, valproate,

carbamazepine

anticonvulsants valproate, carbamazepine

hormones

sleep aids melatonin

glucocorticoids corticotropin, prednisone

The most important intervention in autism is early and intensive remedial education that addresses both behavioral and communication disorders.

Parents require ongoing counseling and support. They must understand that they are not responsible for their child’s condition. Desperate parents may need explicit counseling about the questionable value of unconventional, and often expensive, dietary, medical, and other therapies that, despite being without proved efficacy, are widely used.

Although most patients with autism will remain dependent to some degree as adults, those with adequate social skills may find a specialized niche that enables them to become self-supporting. As a greater number of mildly affected individuals are identified, we may find that the proportion who achieve independence has been underestimated. However, social skills rarely improve enough to permit successful marriage.

(Rapin, I. Autism. N Eng J Med 1997; 337:97-104)

COMMENT: We continue to wait for a breakthrough in the etiology of autism, which in turn would bring more effective treatment, or even prevention. In the mean time, treatment remains symptomatic and empirical both in terms of behavior management and medication. — R.A.