Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by difficulties in social communication and interactions and restricted, repetitive behaviors and interests. It occurs in approximately 1 in 54 children in the US. Boys are four times more likely to be diagnosed with ASD than girls. While its exact causes are unknown, genetic and environmental factors likely play a role. There is no cure for ASD, but early diagnosis and treatment including behavioral therapies can help children develop skills to better manage their symptoms.

2. Introduction
• ASDs are complex neurodevelopmental disorders of unknown etiology. The APA
Diagnostic and statistical manual of mental disorders (DSM -5) revised the definition for
ASD based on two behaviour domains that include difficulties in social communication,
social interaction and unusually restricted, repetitive behaviour, interest, or activities.
• ASD is now frequently diagnosed in toddlers because their atypical development is
being recognized early. It occurs in 1 in 68 children in the USA is about 4 times more
common in boys than in girls.

4. Definition
Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by :
 Difficulties in social communication differences, including verbal and nonverbal
communication.
 Deficits in social interactions.
 Restricted, repetitive patterns of behaviour, interests, or activities, and sensory
problems.

9. INCIDENCE
• In 2020, the CDC (center for disease control and prevention ) reported that approximately 1 in 54 children in the
U.S. is diagnosed with an autism spectrum disorder (ASD), according to 2016 data.
o 1 in 34 boys identified with autism
o 1 in 144 girls identified with autism
 Boys are four times more likely to be diagnosed with autism than girls.
 Most children were still being diagnosed after age 4, though autism can be reliably diagnosed as early as age 2.
 31% of children with ASD have an intellectual disability (intelligence quotient [IQ] <70), 25% are in the
borderline range (IQ 71–85), and 44% have IQ scores in the average to above-average range (i.e., IQ >85).

10. Etiology /Risk factors
Genetic &
familial factors
Prenatal &
perinatal
influences
Neurobiological
factors
Neuropathology
factor

11.  Siblings
 Twins
 < 26 weeks
gestational age (
extremely
premature birth )
 Advanced maternal
& paternal age
 Closer spacing of
pregnancies
 Timothy syndrome

13. • Advanced age of parents
• Fetal exposure to valproate ,
gestational diabetes
• LBW , neonatal hypoxia
,congenital malformation , ABO
/Rh factor incompatibility .

14. Seizures
Abnormalities within limbic system
White matter tract development
Elevated level of serotonin
Dopamine
Environmental exposure during first trimester
(thalidomide, misoprostol, rubella infection,
valproic acid, and organophosphate insecticide
)

16. Red Flags: Early Symptoms of ASD
By 12 months • Does not respond to name
By 14 months • Does not point at objects to show
interest
By 18 months • Does not pretend play
• General
• Avoids eye contact and may want to be alone
Has trouble understanding other people’s feelings or
talking about their feelings
Has delayed speech and language skills
Repeats words or phrases over and over (echolalia)
Gives unrelated answers to questions
Gets upset by minor changes
Has obsessive interests
Makes repetitive movements like flapping hands,
rocking, or spinning in circles
Has unusual reactions to the way things sound,
smell, taste, look or feel

26. DSM -5 diagnostic criteria for autism spectrum disorder
A
Persistent deficits in social communication and interaction across multiple contexts, as manifested by the following current
or by history:
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 interest, emotions or affect; to failure to initiate or respond to social interaction.
2. Deficits in nonverbal communicative behaviours used for social interaction, ranging for example from poorly integrated
verbal and non-verbal communication; to abnormalities in eye contact and body language or deficits in understanding and
use of gestures; to a total lack of facial expressions and non-verbal communication.
3. Deficits in developing, maintaining, and understanding relationships ranging for example, from difficulties’ adjusting
behaviours to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to the absence of
interest in peers.

27. B
Restricted, repetitive patterns of behaviour , interests or activities as manifested by at least two of the following currently or by
history :
1. Stereotyped or repetitive motor movements , use of objects or speech .( e.g., simple motor stereotyped , lining up toys or
flipping objects , echolalia , idiosyncratic phrases )
2. Insistence on sameness , inflexible adherence to routines , or ritualized patterns of verbal or nonverbal behaviour (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 perseverative 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 movement )

28. C
Symptoms must be present in the early developmental period ( may not become fully manifest until social
demands exceed limited capacities , or may be masked by learned strategies in later life )
D
Symptoms cause clinically significant impairment in social ,occupational or other important areas of current
functioning .
E
These disturbances are not better explained by intellectual disability ( intellectual development disorder ) or
global developmental delay.

29. • Specify if :
 With or without accompanying intellectual impairment
 With or without accompanying language impairment
 Associated with a known medical or genetic condition or environmental factor
 Associated with another neurodevelopmental , mental or behavioural disorder
 With catatonia

31. SEVERITY
LEVEL
SOCIAL COMMUNICATION RESTRICTED , REPETIVE
BEHVAIORS
Level 1
Requiring
support
• Without support in place , deficits in social
communication cause noticeable impairments.
• Difficulty initiating social interactions and clear
examples unsuccessful responses to others . May
appear to have decreased interest.
For e.g., a person who is able to speak in full sentences
and engages in communication but fails in
conversation with others , and whose attempts to make
friends are odd and typically unsuccessful .
 Inflexibility of behaviour causes
significant interference with
functioning in one or more contexts .
 Difficulty switching between
activities .
 Problems of organization and
planning hamper independence.

32. SEVERITY
LEVEL
SOCIAL COMMUNICATION RESTRICTED , REPETIVE
BEHVAIORS
Level 2
Requiring
substantial
support
• Marked deficits in verbal and nonverbal social
communication skills ; social impairment apparent
even with support in place.
• Limited initiation of social interactions; and
reduced or abnormal responses to social overtures
from others .
For e.g., a person who speaks simple sentences ,
whose interaction is limited to narrow special interest
and who has markedly odd non-verbal
communication .
 Inflexibility of behaviour , difficulty
coping with change , or other
restricted /repetitive behaviours
appear frequently enough to be
obvious to the casual observer and
interfere with functioning in a
variety of contexts .
 Distress and /or difficulty changing
focus or action .

33. Level 3
Requiring
very
substantial
support
• Severe deficits in verbal and nonverbal
social communication skills cause severe
impairments in functioning.
• Very limited initiation of social interaction
and minimal response to social over tunes
from others .
For e.g., a person with few words of speech
who rarely initiates interaction and when he or
she does makes unusual approaches to meet
needs only and responds to only very direct
social approaches .
 Inflexibility of behaviour ,
extreme difficulty coping with
change , or other restricted
/repetitive behaviours
markedly interfere with
functioning in all spheres .
great distress /difficulty
changing focus or action .

34. SIGN AND SYMPTOMS OF POSSIBLE AUTISM IN PRESCHOOL CHILDREN
( or equivalent mental age)
SPOKEN LANGUAGE
a) Language delay (in babble or words – for example , using fewer than 10 words by the age of 2 yrs.)
b) Regression in or loss of use of speech
c) Spoken language may include unusual features , such as : vocalizations that are not speech like ;odd
;frequent repetition of set words and phrases (echolalia ) ;reference to self by name or “ you” or “she” or
“he” beyond age 3 yrs.
d) Reduced and or infrequent use of language for communication .

35. RESPONDING TO OTHERS
a) Absent or delayed response to name being called ,despite normal hearing .
b) Reduced or absent responsive social smiling .
c) Reduced or absent responsiveness to other people’s facial expressions or feelings .
d) Unusually negative response to the requests of others (“demand avoidance” behaviour ) .
e) Rejection of cuddles initiated by parent or , although the child himself or herself may initiate
cuddles .

36. INTERACTING WITH OTHERS
a) Reduced or absent awareness of personal space or unusually intolerant of people entering their personal
space.
b) Reduced or absent social interest in others , including children of his or her own age -may reject others ;if
interested in others ,he or she may approach others inappropriately ,seeming to be aggressive or disruptive .
c) Reduced or absent initiation of social play with others ,plays alone .
d) Reduced or absent enjoyment of situations the most children like -for example ,birthday parties .
e) Reduced or absent sharing of enjoyment .

37. EYE CONTACT ,POINTING AND OTHER GESTURES
a) Reduced or absent use of gestures and facial expressions to communicate.
b) Reduced and poorly integrated gestures facial expressions, body orientation , eye contact ( looking at people’s eyes when
speaking ) and speech used in social communication .
c) Reduced or absent social use of eye contact .
d) Reduced or absent “ joint attention” ( when 1 person alerts another to something by means of gazing ,finger pointing ,or other
verbal or nonverbal indication for the purpose of sharing interest )
e) Following a point ( looking where the other person points to -may look at hand )
f) Using pointing at or showing objects to share interests

38. IDEAS AND IMAGINATION
a) Reduced or absent imagination and variety of pretend play
UNUSUAL OR RESTRICTED INTERESTS AND /OR RIGID AND REPETITIVE BEHAVIOURS
a) Repetitive “stereotypical” movements such as hand flapping ;body rocking while standing ,spinning ,finger flicking .
b) Repetitive or stereotyped play -for example ,opening and closing doors .
c) Over focused or unusual interests .
d) Extremes of emotional reactivity to change or new situation ;insistence on things being “the same” .
e) Over reaction or under reaction to sensory stimuli ,such as texture ,sounds ,smells .
f) Excessive reaction to the taste ,smell, texture , or appearance of food , or having extreme food fads .

39. DEVELOPMENT CLINICAL COURSE

40. COMORBIDITIES
• In most epidemiologically , approximately 50% exhibit severe or profound intellectual disability , 35% exhibit
mild to moderate intellectual disability and the remaining 20% have IQs in the normal range .
• Verbal skills are typically more impaired than nonverbal skills . Intellectual impairments are not an essential
diagnostic feature of autism; it is necessary and important for the diagnosis of intellectual disability to be made .
Neurologic comorbidities include epilepsy , sleep dysfunction , motor delay , incoordination and gait
disturbance .
• A range of behavioural difficulties can be observed in ASD including hyperactivity , OCD ,self-injury
,aggression , stereotype , tics and affective symptoms(anxiety , depression ,over or under activity ).

41. ASSESSMENT
• Autism diagnostic observation schedule ( ADOS ) which is a semi structured interactive examination by a
professional trained , is the standard diagnostic tool .
• Medical examination , which typically include a physical examination , hearing screen ,a wood’s lamp
examination for signs of tuberculosis and genetic testing which should include chromosomal microarray.
• Unusual feathers in the child ( dysmorphology , staring spells ) should prompt additional evaluation . the
categories of potential organic etiologies include infectious ( meningitis, encephalitis) , endocrinologic (
hypothyroidism) ,metabolic ( homocystinuria ,PKU) ,trauma, toxins or genetic .

43. Screening /case finding
All children should receive autism specific screening at 18 and 24 months of age , in addition to broad
developmental screening at
9 ,18 and 24 months .

46. TREATMENT
• There are no medications that treat the core symptoms of ASD . The U.S. Food and drug administration
( FDA ) has approved two medications for the treatment of irritability associated with ASD :
Risperidone ( Risperdal ; in children and adolescents 5 to 16 years ) and aripiprazole ( in children and
adolescents 6 to 17 years ) .
In youth weighing < 20kg ,the initial dose of risperidone is 0.25mg/day with a target dose of 0.5mg/day and
maximum dose of 3 mg/day .
In those > 20 kg the initial dose is 0.5mg/day with a target dose of 1mg/day and maximum of 3mg/day .
For aripiprazole , the initial dose is 2mg/day with a target dose of 5-10mg/day and maximum dose of
15mg/day .

47. • Intranasal Oxytocin ( IO) is a novel approach to treating ASD . In preliminary studies ,IO leads to increased
social interactions, better speech comprehension , reduced repetitive behaviours and functional MRI evidence
of improved social interaction. There is currently a large clinical trial testing the efficacy of IO .
Individuals with ASD may be non-verbal , so response to medication is often judged by
caregiver report .

49. NURSING MANAGEMENT
• Risk for self-mutilation or self-injury related to neurological ,cognitive or
social deficits .
• Impaired social interaction related to inability to trust ; neurological alterations,
evidenced by lack of responsiveness to , or interact in people .
• Impaired verbal communication related to withdrawal into self ;neurological
alterations,evidencenced by inability or unwillingness to speak; lack of non-verbal
expression
• Disturbed personal identity related to neurological alterations ; delayed developmental stage ,evidence by
difficulty separating own physiological and emotional needs and personal boundaries from those of
others .

50. • Although there is no cure for ASD ,numerous therapies have been used . The most promising results
have been through highly structured and intensive behaviour modification programs .
• In general , the objective in treatment is to promote positive reinforcement , increase social
awareness of others , teach verbal communication skills and decrease unacceptable behaviour .
Providing a structured routine for the child to follow is a key in the management of ASD .
• Children with ASD need to be introduced slowly to new situations , with visits with staff caregivers
kept whenever possible . Because these children have difficulty organizing their behaviour and
redirecting their energy , they need to be told directly what to do . Communication should be at the
child’s developmental level , brief and concrete .

51. • FAMILY SUPPORT
• ASD as with so many other chronic conditions , involves the entire family and often becomes “ a family disease”. Nurses can
help alleviate the guilt and shame often associated with this disorder by stressing what is known from a biologic standpoint
and by providing family support . It is imperative to help parents understand that they are not the cause of the child’s
condition .
• Parents need expert counselling early in the course of the disorder and should be referred to the autism society website . The
society provides information about education , treatment programs ,techniques and facilities such as camps and group homes
. Other helpful resources for parents of children with ASD are the local and state departments of mental health and
developmental disabilities.
• As much as possible , the family is encouraged to care for the child in the home . With the help of family support programs
in many states , families are often able to provide home care and assist with the educational services the child needs . As the
child approaches adulthood and the parents becomes older , the family may require assistance in locating a long-term
placement facility .

52. RESEARCH ARTICLE
• Study : Early features of autism spectrum disorder: a cross-sectional study.
• Authors: Parmeggiani Antonia , Corinaldesi Arianna ,Posar Annio
• Date : Nov ,2019
• Objectives : This study aimed to report on age at onset, early signs, and mode at onset in 105 Italian patients with autism
spectrum disorder, searching for correlations with a series of clinical and instrumental variables.
• Methods : This retrospective cross-sectional study considered the following five categories of symptoms at onset: language,
social interaction and relationships, stereotyped behaviours and activities, motor skills, and regulation. Three modes of
presentation were considered: a delay, a stagnation, or a regression of development, which were defined modes of onset of
autism spectrum disorder.

53. • Results: The first symptoms between 7 and 12 months were evident in 41.9% of cases, and between 13 and 24 months in
27.6%; no significant differences for the age at onset related to diagnosis, etiopathogenesis, early onset epilepsy, and
intelligence quotient level emerged.
• Social interaction and relationships (93.3%) and language (92.4%) were the categories of early signs more represented in
our sample. Delay in spoken language was one of the most common symptoms for a possible diagnosis of autism
spectrum disorder.
• At onset, patients without intellectual disability manifested stagnation more often than delay or regression of
development; patients with a severe/profound intellectual disability more frequently showed delay or regression of
development. Language signs at onset were less frequent in cases with regression, whereas motor skill disorders
prevailed in cases with delay at onset. Feeding problems were more numerous in cases with delay and stagnation of
development.
Conclusions: These data contribute to identifying an early trend of autism spectrum disorder, useful also for paediatricians.

55. CONCLUSIONS
Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by the Difficulties in social
communication differences, including verbal and nonverbal communication, Deficits in social interactions
and Restricted, repetitive patterns of behaviour, interests or activities and sensory problems . Along with the
medical management it is important to use other supportive therapies for the improvement in child’s
condition and its development .

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