Facts About ASDs

People with ASDs handle information in their brain differently than other people.

ASDs are “spectrum disorders.” That means ASDs affect each person in different ways, and can range from very mild to severe. People with ASDs share some similar symptoms, such as problems with social interaction. But there are differences in when the symptoms start, how severe they are, and the exact nature of the symptoms.

Types of ASDs

There are three different types of ASDs: Autistic Disorder (also called “classic” autism) This is what most people think of when hearing the word “autism.” People with autistic disorder usually have significant language delays, social and communication challenges, and unusual behaviors and interests. Many people with autistic disorder also have intellectual disability. Asperger Syndrome People with Asperger syndrome usually have some milder symptoms of autistic disorder. They might have social challenges and unusual behaviors and interests. However, they typically do not have problems with language or intellectual disability. Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS; also called “atypical autism”) People who meet some of the criteria for autistic disorder or Asperger syndrome, but not all, may be diagnosed with PDD-NOS. People with PDD-NOS usually have fewer and milder symptoms than those with autistic disorder. The symptoms might cause only social and communication challenges.

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Signs and Symptoms

ASDs begin before the age of 3 and last throughout a person's life, although symptoms may improve over time. Some children with an ASD show hints of future problems within the first few months of life. In others, symptoms might not show up until 24 months or later. Some children with an ASD seem to develop normally until around 18 to 24 months of age and then they stop gaining new skills, or they lose the skills they once had. Studies have shown that one third to half of parents of children with an ASD noticed a problem before their child’s first birthday, and nearly 80%–90% saw problems by 24 months of age.

It is important to note that some people without an ASD might also have some of these symptoms. But for people with an ASD, the impairments make life very challenging.

A person with an ASD might:

• Not respond to their name by 12 months
• Not point at objects to show interest (point at an airplane flying over) by 14 months
• Not play "pretend" games (pretend to "feed" a doll) by 18 months
• Avoid eye contact and want to be alone
• Have trouble understanding other people's feelings or talking about their own feelings
• Have delayed speech and language skills
• Repeat words or phrases over and over (echolalia)
• Give unrelated answers to questions
• Get upset by minor changes
• Have obsessive interests
• Flap their hands, rock their body, or spin in circles
• Have unusual reactions to the way things sound, smell, taste, look, or feel

Example of Range of Symptoms Following the chart below - a person might have average intelligence, have little interest in other people, use limited verbal language, experience intense self-stimulatory behaviors such as hand-flapping, under-react to pain and over-react to sounds, have very good gross motor skills, and have weaknesses in fine motor skills. These syptoms may vary widely from person to person.

Social Skills

Social issues are one of the most common symptoms in all of the types of ASD. People with an ASD do not have just social “difficulties” like shyness. The social issues they have cause serious problems in everyday life.

Examples of social issues related to ASDs:

• Does not respond to name by 12 months of age
• Avoids eye-contact
• Prefers to play alone
• Does not share interests with others
• Only interacts to achieve a desired goal
• Has flat or inappropriate facial expressions
• Does not understand personal space boundaries
• Avoids or resists physical contact
• Is not comforted by others during distress
• Has trouble understanding other people's feelings or talking about own feelings

Typical infants are very interested in the world and people around them. By the first birthday, a typical toddler interacts with others by looking people in the eye, copying words and actions, and using simple gestures such as clapping and waving “bye bye”. Typical toddlers also show interests in social games like peek-a-boo and pat-a-cake. But a young child with an ASD might have a very hard time learning to interact with other people.

Some people with an ASD might not be interested in other people at all. Others might want friends, but not understand how to develop friendships. Many children with an ASD have a very hard time learning to take turns and share—much more so than other children. This can make other children not want to play with them.

People with an ASD might have problems with showing or talking about their feelings. They might also have trouble understanding other people's feelings. Many people with an ASD are very sensitive to being touched and might not want to be held or cuddled. Self-stimulatory behaviors (e.g., flapping arms over and over) are common among people with an ASD. Anxiety and depression also affect some people with an ASD. All of these symptoms can make other social problems even harder to manage.

Communication

Each person with an ASD has different communication skills. Some people can speak well. Others can’t speak at all or only very little. About 40% of children with an ASD do not talk at all. About 25%–30% of children with an ASD have some words at 12 to 18 months of age and then lose them. Others might speak, but not until later in childhood.

Examples of communication issues related to ASDs:

• Delayed speech and language skills
• Repeats words or phrases over and over (echolalia)
• Reverses pronouns (e.g., says “me” instead of “I”)
• Gives unrelated answers to questions
• Does not point or respond to pointing
• Uses few or no gestures (e.g., does not wave goodbye)
• Talks in a flat, robot-like, or sing-song voice
• Does not pretend in play (e.g., does not pretend to “feed” a doll)
• Does not understand jokes, sarcasm, or teasing

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People with an ASD who do speak might use language in unusual ways. They might not be able to put words into real sentences. Some people with an ASD say only one word at a time. Others repeat the same words or phrases over and over. Some children repeat what others say, a condition called echolalia. The repeated words might be said right away or at a later time. For example, if you ask someone with an ASD, "Do you want some juice?" he or she might repeat "Do you want some juice?" instead of answering your question. Although many children without an ASD go through a stage where they repeat what they hear, it normally passes by three years of age. Some people with an ASD can speak well but might have a hard time listening to what other people say.

People with an ASD might have a hard time using and understanding gestures, body language, or tone of voice. For example, people with an ASD might not understand what it means to wave goodbye. Facial expressions, movements, and gestures may not match what they are saying. For instance, people with an ASD might smile while saying something sad.

People with an ASD might say "I" when they mean "you," or vice versa. Their voices might sound flat, robot-like, or high-pitched. People with an ASD might stand too close to the person they are talking to, or might stick with one topic of conversation for too long. They might talk a lot about something they really like, rather than have a back-and-forth conversation with someone. Some children with fairly good language skills speak like little adults, failing to pick up on the “kid-speak” that is common with other children.

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Unusual Interests and Behaviors

Many people with an ASD have unusual interest or behaviors.

Examples of unusual interests and behaviors related to ASDs:

• Lines up toys or other objects
• Plays with toys the same way every time
• Likes parts of objects (e.g., wheels)
• Is very organized
• Gets upset by minor changes
• Has obsessive interests
• Has to follow certain routines
• Flaps hands, rocks body, or spins self in circles

Repetitive motions are actions repeated over and over again. They can involve one part of the body or the entire body or even an object or toy. For instance, people with an ASD might spend a lot of time repeatedly flapping their arms or rocking from side to side. They might repeatedly turn a light on and off or spin the wheels of a toy car. These types of activities are known as self-stimulation or “stimming.”

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People with an ASD often thrive on routine. A change in the normal pattern of the day—like a stop on the way home from school—can be very upsetting to people with an ASD. They might “lose control” and have a “melt down” or tantrum, especially if in a strange place.

Some people with an ASD also may develop routines that might seem unusual or unnecessary. For example, a person might try to look in every window he or she walks by a building or might always want to watch a video from beginning to end, including the previews and the credits. Not being allowed to do these types of routines might cause severe frustration and tantrums.

Other Symptoms

Some people with an ASD have other symptoms. These might include:

• Hyperactivity (very active)
• Impulsivity (acting without thinking)
• Short attention span
• Aggression
• Causing self injury
• Temper tantrums
• Unusual eating and sleeping habits
• Unusual mood or emotional reactions
• Lack of fear or more fear than expected
• Unusual reactions to the way things sound, smell, taste, look, or feel

People with an ASD might have unusual responses to touch, smell, sounds, sights, and taste, and feel. For example, they might over -or under-react to pain or to a loud noise. They might have abnormal eating habits. For instance, some people with an ASD limit their diet to only a few foods. Others might eat nonfood items like dirt or rocks (this is called pica). They might also have issues like chronic constipation or diarrhea.

People with an ASD might have odd sleeping habits. They also might have abnormal moods or emotional reactions. For instance, they might laugh or cry at unusual times or show no emotional response at times you would expect one. In addition, they might not be afraid of dangerous things, and they could be fearful of harmless objects or events.

Development Children with an ASD develop at different rates in different areas. They may have delays in language, social, and learning skills, while their ability to walk and move around are about the same as other children their age. They might be very good at putting puzzles together or solving computer problems, but they might have trouble with social activities like talking or making friends. Children with an ASD might also learn a hard skill before they learn an easy one. For example, a child might be able to read long words but not be able to tell you what sound a "b" makes. Children develop at their own pace, so it can be difficult to tell exactly when a child will learn a particular skill. But, there are age-specific developmental milestones used to measure a child’s social and emotional progress in the first few years of life. To learn more about developmental milestones, visit “Learn the Signs. Act Early,” a campaign designed by CDC and a coalition of partners to teach parents, health care professionals, and child care providers about early childhood development, including possible ”red flags” for autism spectrum disorders.

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Diagnosis

ASDs can sometimes be detected at 18 months or younger. By age 2, a diagnosis by an experienced professional can be considered very reliable. However, many children do not receive a final diagnosis until much older. This delay means that children with an ASD might not get the help they need.

Diagnosing an ASD takes two steps:

Developmental Screening

Developmental screening is a short test to tell if children are learning basic skills when they should, or if they might have delays. During developmental screening the doctor might ask the parent some questions or talk and play with the child during an exam to see how she learns, speaks, behaves, and moves. A delay in any of these areas could be a sign of a problem.

All children should be screened for developmental delays and disabilities during regular well-child doctor visits at:

• 9 months
• 18 months
• 24 or 30 months
• Additional screening might be needed if a child is at high risk for developmental problems due to preterm birth, low birth weight or other reasons.

In addition, all children should be screened specifically for ASDs during regular well-child doctor visits at:

• 18 months
• 24 months
• Additional screening might be needed if a child is at high risk for ASDs (e.g., having a sister, brother or other family member with an ASD) or if behaviors sometimes associated with ASDs are present

It is important for doctors to screen all children for developmental delays, but especially to monitor those who are at a higher risk for developmental problems due to preterm birth, low birth weight, or having a brother or sister with an ASD.

If your child’s doctor does not routinely check your child with this type of developmental screening test, ask that it be done.

If the doctor sees any signs of a problem, a comprehensive diagnostic evaluation is needed.

Comprehensive Diagnostic Evaluation

The second step of diagnosis is a comprehensive evaluation. This thorough review may include looking at the child’s behavior and development and interviewing the parents. It may also include a hearing and vision screening, genetic testing, neurological testing, and other medical testing.

In some cases, the primary care doctor might choose to refer the child and family to a specialist for further assessment and diagnosis. Specialists who can do this type of evaluation include:

• Developmental Pediatricians (doctors who have special training in child development and children with special needs)
• Child Neurologists (doctors who work on the brain, spine, and nerves)
• Child Psychologists or Psychiatrists (doctors who know about the human mind)

Treatment

Even if your child has not been diagnosed with an ASD, he or she may be eligible for early intervention treatment services. The Individuals with Disabilities Education Act (IDEA) says that children under the age of 3 years (36 months) who are at risk of having developmental delays may be eligible for services. These services are provided through an early intervention system in your state. Through this system, you can ask for an evaluation.

In addition, treatment for particular symptoms, such as speech therapy for language delays, often does not need to wait for a formal ASD diagnosis.

There is no single best treatment for all children with ASDs. However, well-planned, structured teaching of specific skills is very important. Some children respond well to one type of treatment while others have a negative response or no response at all to the same treatment. Before deciding on a treatment program, it is important to talk with the child’s health care providers to understand all the risks and benefits. It is also important to remember that children with ASDs can get sick or injured just like children without ASDs. Regular medical and dental exams should be part of a child’s treatment plan. Often it is hard to tell if a child’s behavior is related to the ASD or is caused by a separate health condition. For instance, head banging could be a symptom of the ASD, or it could be a sign that the child is having headaches. In those cases, a thorough physical exam is needed. Monitoring healthy development means not only paying attention to symptoms related to ASDs, but also to the child’s physical and mental health, as well.

Types of Treatments

The National Institute of Mental Health and the Autism Society of America suggest a list of questions parents can ask when planning treatments for their child.

There are many different types of treatments available. For example, auditory training, discrete trial training, vitamin therapy, anti-yeast therapy, facilitated communication, music therapy, occupational therapy, physical therapy, and sensory integration.

The different types of treatments can generally be broken down into the following categories:

• Behavior and Communication Approaches
• Dietary Approaches
• Medication
• Complementary and Alternative Medicine

Behavior and Communication Approaches

According to reports by the American Academy of Pediatrics and the National Research Council, behavior and communication approaches that help children with ASDs are those that provide structure, direction, and organization for the child in addition to family participation.

Applied Behavior Analysis (ABA)

A notable treatment approach for people with an ASD is called applied behavior analysis (ABA). ABA has become widely accepted among health care professionals and used in many schools and treatment clinics. ABA encourages positive behaviors and discourages negative behaviors in order to improve a variety of skills. The child’s progress is tracked and measured.

There are different types of ABA. Following are some examples:

• Discrete Trial Training (DTT)
  DTT is a style of teaching that uses a series of trials to teach each step of a desired behavior or response. Lessons are broken down into their simplest parts and positive reinforcement is used to reward correct answers and behaviors. Incorrect answers are ignored.
• Early Intensive Behavioral Intervention (EIBI)
  This is a type of ABA for very young children with an ASD, usually younger than five, and often younger than three.
• Pivotal Response Training (PRT)
  PRT aims to increase a child’s motivation to learn, monitor his own behavior, and initiate communication with others. Positive changes in these behaviors should have widespread effects on other behaviors.
• Verbal Behavior Intervention (VBI)
  VBI is a type of ABA that focuses on teaching verbal skills.

Other therapies that can be part of a complete treatment program for a child with an ASD include:

Developmental, Individual Differences, Relationship-Based Approach (DIR; also called “Floortime”)

Floortime focuses on emotional and relational development (feelings, relationships with caregivers). It also focuses on how the child deals with sights, sounds, and smells.

Treatment and Education of Autistic and related Communication-handicapped CHildren (TEACCH)

TEAACH uses visual cues to teach skills. For example, picture cards can help teach a child how to get dressed by breaking information down into small steps.

Occupational Therapy
Occupational therapy teaches skills that help the person live as independently as possible. Skills might include dressing, eating, bathing, and relating to people.

Sensory Integration Therapy
Sensory integration therapy helps the person deal with sensory information, like sights, sounds, and smells. Sensory integration therapy could help a child who is bothered by certain sounds or does not like to be touched.

Speech Therapy
Speech therapy helps to improve the person’s communication skills. Some people are able to learn verbal communication skills. For others, using gestures or picture boards is more realistic.

The Picture Exchange Communication System (PECS)
PECS uses picture symbols to teach communication skills. The person is taught to use picture symbols to ask and answer questions and have a conversation.

Visit the Autism Speaks or Easter Seals website to read more about these therapies.

Dietary Approaches

Some dietary treatments have been developed by reliable therapists. But many of these treatments do not have the scientific support needed for widespread recommendation. An unproven treatment might help one child, but may not help another.

Many biomedical interventions call for changes in diet. Such changes include removing certain types of foods from a child’s diet and using vitamin or mineral supplements. Dietary treatments are based on the idea that food allergies or lack of vitamins and minerals cause symptoms of ASDs. Some parents feel that dietary changes make a difference in how their child acts or feels.

If you are thinking about changing your child’s diet, talk to the doctor first. Or talk with a nutritionist to be sure your child is getting important vitamins and minerals.

Medication

To learn more about medications and ASDs go to National Institute of Mental Health autism website.

Complementary and Alternative Treatments

To relieve the symptoms of ASDs, some parents and health care professionals use treatments that are outside of what is typically recommended by the pediatrician. These types of treatments are known as complementary and alternative treatments (CAM). They might include special diets, chelation (a treatment to remove heavy metals like lead from the body), biologicals (e.g., secretin), or body-based systems (like deep pressure).

These types of treatments are very controversial. Current research shows that as many as one third of parents of children with an ASD may have tried complementary or alternative medicine treatments, and up to 10% may be using a potentially dangerous treatment. Before starting such a treatment, check it out carefully, and talk to your child’s doctor.

To learn more about CAM therapies, go to the National Center for Complementary and Alternative Medicine Get the Facts webpage.

Additional Treatment Resources

The National Institute on Deafness and Other Communication Disorders has a website to help individuals with an ASD who have communication challenges.

The National Institute of Dental and Craniofacial Research has a website to help health professionals with the oral health care needs of patients with an ASD.

Clinical Trials.Gov lists federally funded clinical trials that are looking for participants. If you or someone you know would like to take part in an autism study, go to the website and search “autism.”

The Autism Treatment Network (ATN) seeks to create standards of medical treatment that will be made broadly available to physicians, researchers, parents, policy makers, and others who want to improve the care of individuals with autism. ATN is also developing a shared national medical database to record the results of treatments and studies at any of their five established regional treatment centers.

Causes and Risk Factors

We do not know all of the causes of ASDs. However, we have learned that there are likely many causes for multiple types of ASDs. There may be many different factors that make a child more likely to have an ASD, including environmental, biologic and genetic factors.

• Most scientists agree that genes are one of the risk factors that can make a person more likely to develop an ASD.
• Children who have a sibling or parent with an ASD are at a higher risk of also having an ASD.
• ASDs tend to occur more often in people who have certain other medical conditions. About 10% of children with an ASD have an identifiable genetic disorder, such as Fragile X syndrome, tuberous sclerosis, Down syndrome and other chromosomal disorders.
• Some harmful drugs taken during pregnancy have been linked with a higher risk of ASDs, for example, the prescription drugs thalidomide and valproic acid.
• We know that the once common belief that poor parenting practices cause ASDs is not true.
• There is some evidence that the critical period for developing ASDs occurs before birth. However, concerns about vaccines and infections have led researchers to consider risk factors before and after birth.

ASDs are an urgent public health concern. Just like the many families affected in some way by ASDs, CDC wants to find out what causes the disorder. Understanding the risk factors that make a person more likely to develop an ASD will help us learn more about the causes. We are currently working on one of the largest U.S. studies to date, called Study to Explore Early Development (SEED). SEED is looking at many possible risk factors for ASDs, including genetic, environmental, pregnancy, and behavioral factors.

Who is Affected

More people than ever before are being diagnosed with an ASD. It is unclear exactly how much of this increase is due to a broader definition of ASDs and better efforts in diagnosis. However, a true increase in the number of people with an ASD cannot be ruled out. We believe the increase in ASD diagnosis is likely due to a combination of these factors.

Within the past decade, CDC’s Autism and Developmental Disabilities Monitoring (ADDM) Network has been estimating the number of people with an ASD in the U.S. We have learned a lot about how many children in the U.S. have an ASD. It will be important to use the same methods to track how the number of people with an ASD is changing over time in order to learn more about the disorders.

If You’re Concerned

If you or the doctor is still concerned, ask the doctor for a referral to a specialist who can do a more in-depth evaluation of your child. Specialists who can do a more in-depth evaluation and make a diagnosis include:

• Developmental Pediatricians (doctors who have special training in child development and children with special needs)
• Child Neurologists (doctors who work on the brain, spine, and nerves)
• Child Psychologists or Psychiatrists (doctors who know about the human mind)

At the same time, call your state’s public early childhood system to request a free evaluation to find out if your child qualifies for intervention services. This is sometimes called a Child Find evaluation. You do not need to wait for a doctor’s referral or a medical diagnosis to make his call.

Where to call for a free evaluation from the state depends on your child’s age:

• If your child is not yet 3 years old, contact your local early intervention system.

  You can find the right contact information for your state by calling the National Dissemination Center for Children with Disabilities (NICHCY) at 1-800-695-0285.

  Or visit the NICHCY website. Once you find your state on this webpage, look for the heading “Programs for Infants and Toddlers with Disabilities: Ages Birth through 3”.

• If your child is 3 years old or older, contact your local public school system.

  Even if your child is not yet old enough for kindergarten or enrolled in a public school, call your local elementary school or board of education and ask to speak with someone who can help you have your child evaluated.

  If you’re not sure who to contact, call the National Dissemination Center for Children with Disabilities at 1.800.695.0285 or visit the NICHCY website. Once you find your state on this webpage, look for the heading “Programs for Children with Disabilities: Ages 3 through 5”.

Research shows that early intervention services can greatly improve a child’s development. In order to make sure your child reaches his or her full potential, it is very important to get help for an ASD as soon as possible.