Early recognition of autism is important for maximizing developmental outcomes through early intervention. Autism is characterized by impairments in social communication and interaction, as well as restrictive and repetitive behaviors. Diagnosis involves screening during well-child visits followed by a comprehensive evaluation by a team using tools like the ADOS and ADI-R. While there is no cure, treatments aim to improve skills through behavior, communication, and occupational therapies while also addressing sensory and medical issues.

1. EARLY
RECOGNITION OF
AUTISMD R R A J E S H K M A N D A L
M D I N T E R N A L M E D I C I N E

2. OVERVIEW
• Understanding Autism ( screening, Diagnosis ..)
• Signs and Symptoms to recognize Autism
• Importance of Early diagnosis and Early Intervention
• Sensory Dysfunction in Autism
• Neurocognitive theory on Autism
• Short Introduction of few Evidence based therapies in Autism

3. UNDERSTANDING AUTISM

4. AUTISM
• It is neurodevelopmental disability leading to impairment in the areas of
• Social communication
• Social reciprocity ( difficulty in relating to people)
• Restrictive and Repetative behavior
• People with ASDs handle information in their brain differently than other people with
different behavioral challenges.

5. TRIAD OF IMPAIRMENT
Communication
Flexibility of thinkingSocialisation

6. SOCIAL RESPONSIVENESS –
BUILDING BLOCKS OF SOCIAL
SKILLS
Joint Attention – milestones
• 8 months – follows parent’s gaze
• 10 – 12 months – follows a point
• 12 – 14 months – points to request
• 14 to 16 months – points to draw parent’s attention
Pointing is accompanied by eye gaze

7. SOCIAL
RESPONSIVENESS
• Orienting to name – usually by 8 -10 m
• Parents often worry about hearing
• Social referencing – novel stimulus- look at parent for reaction. Eg. Throw things and
look back to parents for their reaction.

8. SOCIAL DEFICITS IN OLDER
CHILDREN
• Difficulty forming relationships with peers
• Diff understanding rules of games, taking turns
• Seem independent, naïve

9. SOCIAL SKILLS
Social issues are one of the most common symptoms in 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

11. PLAY SKILLS – SYMBOLIC PLAY
KEY FOR LANGUAGE DEVELOPMENT

12. PLAY IN CHILDREN WITH
AUTISM
• Play is characteristically different
• Toys and objects used in inflexible manner-spinning, rolling
• Prefers blocks, puzzles, clay dough, letters ,numbers to cars, dolls
• Very little reciprocal play-turn taking

17. ABSENCE OF IMAGINATIVE PLAY
MAY BE A KEY SYMPTOM OF
AUTISM

18. COMMUNICATION
• Verbal / Non verbal
• Receptive/ Expressive
• Communication partner
• Infant start their communicative intent since ?

19. COMMUNICATION
Each person with an ASD has different communication skills.
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.1
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 "you" 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)
• Have literal understanding of language.
• Does not understand jokes, sarcasm, or teasing

20. UNUSUAL INTERESTS AND
REPETITIVE 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

27. AUTISM IS THE
SPECTRUM DISORDER

28. CASE 1
• A 2 years old boy, physically growth age appropriate . In the playground , he likes to
run and chase his sister and father, sometimes throws ball. Occasionally , looks into
mothers face for his interested need. usually doesn't make eye contact with strangers.
Has no significant language except for some sound. Unable to ask for his demands
instead uses parents hand and puts on object. Runs after children but would not take
part in playing with them. Has limited interest in toy car , lining them and looking at
them instead of playing toy car.

29. CASE 2
• A 5 year old child goes to kindergarten. Parents say he knows and sings most of the
bollywood songs and repeats what they say. Mostly ,he is happy watching songs on
TV and collecting sticks. At school, he has difficulty in sitting for long time. He has
difficulty following teachers instruction and catch up with work like other peers. He has
difficulty participating in group games ( would walk away or engage himself gazing ). At
playground he usually collects sticks and line them up.

30. CASE 3
• 26 month old male child brought by his parents for consultation for behavior problems.
He had frequent temper tantrums, crying for unknown reasons and threw things in
anger and parents had difficulty in understanding him. He is the first child, normal
pregnancy and delivery with a birth weight of 2.7 kg. According to his parents he
achieved all his milestones at the normal ages and there were no delays except in
speech. You find that he had no meaningful vocabulary, was unable to comprehend
simple instructions. He had pointing and made good eye contact and imitated well. He
interacted well with family members but did not respond to his name when called. He
was able to follow one step command with gestures but unable to follow without
gestures, unable to show body parts when requested, could not identify pictures like
car, banana in a picture book, though he randomly pointed to pictures and looked at
the mother. His general health was otherwise normal except for frequent coughs and
colds. There is a family history of speech delay in the father’s side.

31. CASE 4
• 3 year old female child is brought to you for delays in speech and language
development. She is the second child, born at 33 weeks, 2.0kg in weight. Except for
jaundice for which she was treated with phototherapy for 5 days, there were no other
problems. According to her parents, she was slightly delayed in all her milestones
compared to their first child. She had a vocabulary of 20 words, spoke in single words,
was beginning to use 2 word phrases, mostly communicated non -verbally, had good
pointing, and responded to her name and other commands. You find that she is bright
and friendly, shows you her doll, follows one step commands but unable to follow two
step commands. She is able to show her head, nose and hands. She is able to make a
3 cube bridge and copy a circle.
•

32. ALARMS
• Not having age appropriate verbal and gestural communication
• Not having back and forth response to action and conversation.
• Not interested in people, more interested on object
• Lack showing and sharing ( joint attention)

33. 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

34. DEVELOPMENTAL
DIFFERENCE
• Children with an ASD develop at different rates in different areas.
• 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.

35. Rahul, a 3 year old with Down Syndrome
0
12
24
36
48
Motor Adaptive Communication Cognitive Social
Series1
Rohan, a 3 year old with autism
0
12
24
36
48
Motor Adaptive Communication Cognitive Social

36. SENSORY PROCESSING
• Senses: Tactile, Auditory, Smell ,
Taste, Vestibular ( Balance) ,
Proprioception (aware about body
posture)
• Hyperactive
• Hypoactive

37. • Most will have sensory processing difficulty.
• Makes it hard to respond to sensory
information and organise their body to
match the environment.

38. SOME MAY AVOID SOME SENSES

39. SOME MAY SEEK SOME
SENSES

40. Hitting Scratching
Screaming Perseverative Language
Hair pulling
Head banging
CHALLENGING BEHAVIOURS: A CONSEQUENCE
Differences in social understanding
Difficulties in communication
Limited interests and repetitive behaviours
Sensory processing issues
Learning Style Issues

41. SOME OF THE MORE PROMISING
NEUROCOGNITIVE THEORIES
• Theory of Mind
• Central Coherence
• Executive Function

42. T H E O RY O F M I N D

43. • Theory of mind refers to otion that many autustic individuals donot understand that
otherpeople may have theirown thoughts,plan and point of view.
• difficulty in understanding others belief,attitude and emotions

44. C E N T R A L
C O H E R E N C E

45. • mindblindness
• unable to build on fundamental step to intruit what others are
thinking,perceiving,intending or believing
• blind to others mental states
• not psychotic but wiered from birth
• Eg; A person with bat, ask to play ball or smash my skull

46. EXECUTIVE
DYSFUNCTION
• Difficulty in planning, sequencing, organizing, time management
• Difficulty switching focus
• Difficulty in Multitasking.
• Difficulty in self regulation
• Difficulty in impulse control

47. AUTISM
70% have normal to high IQ
According DSM-V (2013)to support need
• L1- Requiring support
• L2- Requiring subsequent support
• L3- Requiring very substantial support

48. AUTISM IS NOT
• Psychosocial disorder.
• Intellectual Disability.

49. • 1/68 estimated data from CDC .
• Average prevalence Estimated 1% but recent study in South Korea found prevalence
of 2.6%.
• 5 times more prevalant in boys than in girls.
• 3rd most common developmental disability.
• It is assumed no significant variation in prevalance world wide.
• Found among all socioeconomic, different race, cultural group of people.

50. Prevalence
is rising
:WHO
claims it
being global
public
health cirisis

51. • Autism can be found with comorbid conditions like phenyl ketonurea, Fragile X-
syndrome, tuberous sclerosis, Learning Difficulties, Downs Syndrome, CP, ID
etc.
• ADHD in 50%
• ASD more prevalant in Peadiatric population when in combined no# of Cancer,
Diabetes .

52. ETIOLOGY
• Probably no single etiology.
• Probably more than one gene responsible for its vulnerability.
• Siblings have 15-20% chance of getting diagnosed with same condition.

53. • Likely interplay of genetic predisposition and precepitating events
Environmental
Infectious
Immunologic
others
• Large multisite studies are underway .
• 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.

54. RISK FACTORS
• Children who have a sibling or parent with an ASD are at a higher risk of also having
an ASD.
• When taken during pregnancy, the prescription drugs valporic acid and thalidomide
have been linked with a higher risk of ASDs.
• A small percentage of children who are born prematurely or with low birth weight are at
greater risk for having ASDs.

55. DIAGNOSIS
• No defenetive medical test.
• Team of people look at the child’s behavior and development , parents interview is
required to make a diagnosis.
• Screening
• Comprehensive Evaluation (DSM-v)

56. DEVELOPMENTAL
SCREENING
• During developmental screening the doctor might ask the parent some questions or
talk and play with the child 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.
• Also screening 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
• If the doctor sees any signs of a problem, a comprehensive diagnostic evaluation is
needed.

57. COMPREHENSIVE
DIAGNOSTIC EVALUATION
• This thorough review may include looking at the child’s behavior and development and
interviewing the parents.
• Team includes Development Paediatrician, clinical Psychologist, child psychiatrist,
Speech Language Pathologist, OT , Special Educator etc.

58. DIAGNOSTIC TOOL
There are many tools to assess ASDs in young children, but no single tool should be used as the
basis for diagnosis. Diagnostic tools usually rely on two main sources of information—parents’
or caregivers’ descriptions of their child’s development and a professional’s observation of the
child’s behavior.
Selected examples of diagnostic tools:
• Autism Diagnosis Interview – Revised (ADI-R)[7]
A clinical diagnostic instrument for assessing autism in children and adults. The instrument
focuses on behavior in three main areas: reciprocal social interaction; communication and
language; and restricted and repetitive, stereotyped interests and behaviors. The ADI-R is
appropriate for children and adults with mental ages about 18 months and above.
• Autism Diagnostic Observation Schedule – Generic (ADOS-G)[8]
A semi-structured, standardized assessment of social interaction, communication, play, and
imaginative use of materials for individuals suspected of having ASDs.
Brief assessment suitable for use with any child over 2 years of age. CARS includes items
drawn from five prominent systems for diagnosing autism; each item covers a particular
characteristic, ability, or behavior.
• Gilliam Autism Rating Scale – Second Edition (GARS-2)[10]
Assists teachers, parents, and clinicians in identifying and diagnosing autism in individuals
ages 3 through 22. It also helps estimate the severity of the child’s disorder.
In addition to the tools above, the American Psychiatric Association's Diagnostic and Statistical
Manual-V, Text Revision (DSM-V-TR) provides standardized criteria to help diagnose ASD.

59. DIFFICULTIES IN
DIAGNOSING AUTISM
• As all the criterias may not be fulfilled in very young
children
• Associated with co-morbid conditions like
Mood and Anxiety disorders
Attention-deficit/hyperactivity disorder (ADHD)
• Additional Associated Disorders include:
Cognitive impairment (30-70%)
Seizures (25%)

60. CHALLENGES
CONTINUES.........
• Does not have physical findings or dysmorphism.
• Lack of awareness in families and delay in help
seeking.
• Lack of awareness and knowledge in physicians.
Goma Kumari Khatri, Sharad Raj Onta, Suresh Tiwari, BP ChoulagaiKnowledge and Management
Practices of Paediatricians about Autism Spectrum Disorder in Kathmandu, Nepal J Nep Paedtr Soc 2010;31(2):98-104

61. WHY EARLY
IDENTIFICATION AND
DIAGNOSIS OF AUTISM IS
IMPORTANT?
Child Factor:
• Maximises developmental outcome
• Brain plasticity ; move towards more typical developmental trajectory
• Secondary behaviors may be prevented or minimised
Family factors:
• Parental satisfaction in early diagnosis
• Seeking services ; access to professional support earlier
• Better equipped to help their child before symptoms become unmanageable
• Families become better prepared to deal with challenges ; begin adjustment period and structure the
future.

62. TREATMENT
• Early Intervention ( birth – age 3) has been proven being very effective towards better
prognosis.
• No cure found till date.

63. TYPES OF DIFFERENT
TREATMENT
The different types of treatments can generally be broken down into the following
categories:
• Behavior and Communication Approaches (Therapeutics )
• Dietary Approaches
• Medication

64. • 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

65. SOME OF THE SUCCESSFUL
THERAPIES
• ABA/VBA
• TEACCH-Treatment and Education of Autistic and related
Communication Handicapped Children ( structured teaching)
• Visual Support

66. Applied Behaviour Analysis(ABA)
The ABC format
 A – Antecedent
 B – Behaviour
 C – Consequence

67. ABCs
• A – Antecedent : Something happens before
the behaviour
• B – Behaviour : The person says or does
something observable, specific,
measurable
• C – Consequence : Something follows the
behaviour

68. VISITING THE NEIGHBOURHOOD SHOP NEHA
GRABS A BAG OF CHIPS AND HER MOTHER
BUYS IT FOR HER.
Her mother
buys it for
her
C
Neha grabs a
bag of chips
B
Visiting the
neighbourhood
A

69. Behaviour Modification
• To teach our children new skills
• To strengthen and maintain existing
desired behaviours
• Changing or eliminating undesired
behaviour

70. How can we modify?
By
• Manipulating the consequence
• Manipulating the antecedant
And
• Giving an appropriate alternative behaviour

71. Behaviour
Hitting
AppropriateInappropriate
Punching bagSitting in the class
Praying
Pretanding lika a
bird
Flapping
Spitting Dinning table Brushing teeth

72. TEACCH-TREATMENT AND EDUCATION
OF AUTISTIC AND RELATED
COMMUNICATION HANDICAPPED
CHILDREN
Developed by Eric Schopler, founder of Division
Is a system of organising the environment, time
and activities that helps people with autism
understand what to expect and what is expected
from them

77. FUNCTIONAL
COMMUNICATION
TRAINING (FCT)
• This treatment is always based on the insights from a FBA. It is used to target
inappropriate behaviors by replacing them with more appropriate communication
strategies. Eg. Asking for water instead of biting .

78. COMMUNICATION
THERAPY
• Get on childs level , get attention then give instruction and follow through it.
• Depending on childs ability encourage to show communication intention, repeat word ,
gesture .
• Well stressed speech. Eg.
“sit on the sofa” , “ sit on the sofa”
• Speak from childs perspective
“we are going to shop now” v/s “we are going now”
• Use clear language. Eg. “ put the book on the table” v/s “put this there”

79. Use visuals and words together to help them understand clear .
• For non- verbal child use picture , gesture along with words.
• For those who repeat words , its great opportunity to teach them develop further
speech ( VBA)
• If child has short phrases keep adding words to them.
• Be consistent across people.
• Provide more opportunities to communicate instead of giving things easily.
• Provide word or explain actions in everyday routines.
• Maximize incidental learning eg. concepts

80. AUGMENTIVE AND
ALTERNATIVE
COMMUNICATION (AAC)
• The use of mobile devices to represent language and provide voice output for
communication .
• Language can be represented as letters, words or phrases and can be paired with
pictures or symbols to support comprehension and expression.

81. PHASE IV: SENTENCE
STRUCTURE

82. PHASE IV: ATTRIBUTES

84. VISUAL SUPPORTS THAT
GIVE INFORMATION IN A
CONCRETE WAY
• Real Objects
• Pictures
• Schedules
• Calendars
• Choice boards and menu
• Timers

88. PROVIDE STRUCTURE AND
DISPLAY EXPECTATION

89. Autism Care Nepal Society
Autism
Services
parents and
Teachers
Training
Awareness Advocacy Research

90. REFERRAL FOR DIAGNOSIS AND
THERAPY
• TUTH, Paediatric Department, Child
Care Unit
• Kanti Children Hospital , Child
psychiatry
• Department, Child Neurology Unit
• AutismCare Nepal Society (ACNS)
• ACNS:
• Diagnosis: ADOS , ADI-R (
psychologist)
• Assessment and therapy:
• Functional assessment and therapeutic
counselling
• Occupational therapy assessment and
therapeutic guidance
• Physiotherapy assessment and
guidance
• Speech and language assessment
/communication therapeutic guidance

91. RECOMMENDATION
A- L-A-R-M
• Autism is prevalent
• Listen to parents
• Act early
• Refer
• Monitor

92. • THANK YOU