Autism Spectrum Disorder
I have endeavoured to give an overview of autism spectrum disorder. All the symptoms I mentioned may not be present in one child, and there is significant variability. Differentiating normal variation from pathology is crucial and would need specialist input. This article is only for creating awareness and does not replace a clinician’s advice.
Diagnosis
Autism can be identified as early as 18 months, and signs may appear even earlier. Child health nurses and general practitioners are crucial in making referrals for early diagnosis. This clinical diagnosis is based on criteria that include abnormalities in socialisation such as reciprocation, stereotyped movements, and restricted interests. However, whether these fall into normal behaviour or are considered abnormal is based on detailed clinical assessment.
A specialised team, including occupational therapists, psychologists, speech pathologists, paediatricians, and other relevant professionals, carries out the diagnosis based on many assessments. Detailed reports and observations from kindergartens and schools are vital for accurate diagnoses.
A common issue in clinical practice is concern about speech delay, often raised by the child’s health nurse during routine developmental checks. Although there are established criteria for diagnosis, the clinical signs can vary, and children may show complex, mixed presentations. In my practice, parents often worry about their child’s development and how it compares to what they’ve read online. This misinformation can lead to misdiagnosis, which may impact multiple generations.
Complexity of diagnosis
Autism diagnosis generally doesn’t occur in isolation. Several co-morbidities can be present, such as ADHD, emotional dysregulation, anxiety, depression, intellectual disability, genetic conditions, chromosomal abnormalities, fetal alcohol syndrome, psychiatric conditions, and learning disabilities. Therefore, the clinician must gather information over long-term care as the co-existing diagnoses unravel across multiple appointments. It is clear that, beyond the complexity of diagnosing autism, there is also the challenge of recognising and managing co-occurring conditions.
Interestingly, sometimes it is only when the child is diagnosed that parents realise they might also be on the spectrum. However, it’s natural for some parents to feel guilty that their children’s traits result from their own neurotype. It’s important to recognise that society is still working to understand what is considered normal. Many autistic individuals contribute significantly to our community in various ways. Hence, being kind to oneself and others is paramount. Here, I will outline some of the clinical features of Autism.
Social communication differences
This is an important issue because children with autism find it hard to connect with others. They are already overwhelmed by their own thoughts, and the accompanying anxiety makes it even more difficult. They are often seen as loners in many situations. They struggle to empathise, understand non-verbal cues, reciprocate, hold back-and-forth conversations, or build healthy relationships.
Solitude – Some children find social situations overwhelming and prefer to be alone. For young people who are otherwise functioning well, it may be beneficial to allow them that space rather than pressuring them to socialise. This doesn’t necessarily indicate depression. Distinguishing this requires sound clinical judgement. These children might spend time alone and appear inattentive due to ADHD, but this could be a trait related to their autism diagnosis and might serve as their creative space.
However, avoiding pathological solitude and retracting from all socialisation can be adverse. Hence, a balance should be achieved. The more they drift into solitude, the harder it is for they to socialise later. Therefore, regular attempts to help them be with people they trust would be helpful.
Restricted interests
These interests might seem unusual, such as a fascination with specific toy features like wheels and switches, where the child can focus intensely for hours. I see a child obsessed with playing with water, needing to be gently pulled away from the sink during a consult because they were obsessed with hand washing. They might also follow a restricted diet, possibly due to sensitivities. However, carefully evaluating how much of this interest is considered abnormal is crucial.
They also have positive aspects of this trait. They are detail-oriented, easily notice environmental changes, and spend extended time poring over detailed reports with little trouble. Mr Monk is a nice TV series that exemplifies the traits of Autism in the lead detective, and it is a highly recommended, fun-filled series. However, these traits can be relied upon only if they are not overwhelmed or drowned in intrusive thoughts.
Children with autism need to find the purpose of the activity to remain motivated. Otherwise, they could slip into task avoidance.
Stereotyped movements and rituals
Children may engage in stereotyped activities like stimming or vocalisations. These are mechanisms for self-control, such as touching switches at specific times or walking in certain patterns.
While these behaviours help children regulate themselves, it’s important not to encourage them overly. Conversely, corrective strategies used during anxiety-provoking situations could worsen the behaviour. Extending the time between obsessive thoughts and rituals might be a good strategy using reward systems.
Therefore, interventions should be planned when the child is more emotionally regulated and connected to their caregivers. Discussing how these rituals might prevent them from enjoying life can only be effective if the child is calm rather than in fight-or-flight mode.
Anxiety
This is one of the typical troubles that families struggle with. Children with autism tend not to tolerate crowded places, such as shopping markets, and can throw tantrums at trivial things. This can be quite debilitating for the parents. Separation anxiety is substantial in these children as they feel they are not in their safe environment and with people they know.
Generalised anxiety disorder can be paralysing for these children. This could be the underlying cause of poor self-esteem, POTS (postural tachycardia syndrome), self-harm, eating disorders, etc.
Emotional dysregulation
Emotional dysregulation is a common feature in autism. Some children are constantly in a fight-or-flight state. While some children are skilled at masking their emotional ups and downs at school, they might lash out when they get home, which is a safe environment. It’s essential to recognise that this pattern alone does not diagnose autism, as some children who are introverted, anxious, and sensitive can also demonstrate this behaviour. Therefore, the symptoms should be considered within the broader context.
Screens – One of the main reasons for aggressive behaviours could be a loss of autonomy or control. Children with Autism might feel confused and could find comfort in video games where they have more power and their achievements are validated. This can lead to screen addiction, and not understanding the real reasons behind their reliance on screens may result in ineffective strategies and conversations, leading to an escalation in behavioural issues.
Variation in behaviour across settings – One of the children I provide clinical care for is described as engaging with a lovely nature at school. She doesn’t get into fights, and teachers describe her as calm and composed. However, once she gets home, she is expected to do the dishes and feed the chickens since they live on a large farm. The family consulted me about her emotional outbursts at home and was puzzled by her noticeably different demeanour at school.
A recognition that children with emotional dysregulation might consider home as a safe place to let their steam, and this frame should be realised to understand the variation in behavioural expression. At the time, I suggested avoiding taxing work while tired and allowing the child to relax. I also suggested avoiding questions related to school activities, as some of them may be triggering for the child. Although I had considered a detailed evaluation, the parents reported that she is well managed with simple changes and preferred to leave it without making any further assessments, which I was fine with.
Patterns and predictability – Since these children need structure and predictability, each step of any process must be described in detail so that they can anticipate and prepare for it. Some of these manifestations could be related to significant anxiety, and this needs multidisciplinary management and sometimes medications. Children can have OCD as part of their clinical picture, and they are a way to assert some control over their lives. It’s only logical to understand that children with such cognitive loads find it challenging to focus on tasks and can be inattentive.
Psychologists and occupational therapists can provide lots of strategies for self-regulation, uncovering underlying conditions such as trauma, which might be contributing to some of the symptoms. Dr Krishna Carle’s book “What’s My Colour on the Spectrum” encourages us to think deeply about the varied emotional manifestations of children with Autism.
Puberty – this is a time of significant upheaval for young people. Their anxiety may increase, along with the desire to be accepted by their peer groups. This transitional phase should be anticipated and supported to prevent issues. There is peer pressure to conform, and young people can be drawn into sexualised behaviour and other risk-taking behaviour if not supported well.
Sensory profiling—In many cases, a sensory profile assessment helps to understand the triggers well. I find this particularly useful with children who struggle at school, and the staff find it challenging to comprehend the triggers.
Self-harm
Self-harm is a way of releasing stress and overwhelming thoughts. This is especially worsened at night when the child’s medication effects have worn off. A flurry of thoughts can come to the child, leading to stress and self-harm, particularly if the young person is also having trouble sleeping.
School adjustments
Aggressive behaviour caused by sensory stimuli and difficulty with emotional regulation is a significant challenge these children face. Most of these are signs of fight or flight, as these children perceive danger in any environmental change, especially if it is unexpected. These require tact and detailed explanation in steps so they can better understand the situation.
I have situations where the school cannot manage children with severe autism, especially with rapid staff turnover. I find that children with autism tend to build trust in specific people, and it’s vital to have trusted individuals around them. Spending time on developing trust is crucial in caring for children with autism, and introducing new carers might be a good strategy. Finding peers and friends who can empathise with the child’s condition can be helpful.
Environmental adjustments – They need a trusted person and environmental adjustments for sensory challenges. I provide clinical care for a severely autistic child who thrashes and head bangs at school. One strategy identified in liaison with an occupational therapist was to pad the walls to prevent head injuries. Although this isn’t the whole solution, safety measures must sometimes be implemented. Some modifications, such as using headphones to reduce auditory stimulation and distraction, flexible learning options and dedicating time to oneself in rooms designed for quiet, would be helpful.
Consistent plans – I often hold multidisciplinary meetings with the school to develop a tailored strategy for autistic children. The key is to ensure consistency in managing the children, which is maintained across all staff members.
Parenting styles
Since emotional dysregulation in these children is predominantly related to loss of control or autonomy, it’s important to provide choices and work with the child so that they feel valued and accepted. This might mean that the parenting style needs changing, which would totally differ from what the adults experienced when they were children.
One key factor in helping children with autism is for parents to develop skills in understanding the underlying factors that underpin behaviours. Only then can they empathise with their children, be kind, provide support, and accept them nonjudgmentally.
Management
Depending on the severity, the clinician can decide the appropriate level of Autism based on function and advocate for funding and support. This is one of the prime reasons the NDIS wants a paediatrician’s evaluation and appraisal of the situation.
Several professionals are involved in the treatment team, including a paediatrician, developmental paediatrician, psychologist, occupational therapist, speech pathologist, dietitian, and positive behaviour support practitioner.
Some children might refuse to see the benefits of therapies and may not engage, especially if they aren’t involved in the decision-making process and the experience isn’t enjoyable. I suggest offering choices, such as selecting the professional they work with and the mode, like online. However, accepting therapies can be challenging and should be approached with care.
Coexisting medical conditions
Identifying and treating co-existing conditions such as iron deficiency, thyroid conditions, multiple food allergies, constipation, unrecognised infections (e.g., ear, UTI, or dental), and coeliac disease is crucial, as these co-existing medical conditions can underpin some behavioural changes.
I have some children with sleep-disordered breathing due to being overweight and obese. This can then lead to increasing behavioural issues during the day. One of the common medications used in behavioural conditions, Risperidone, can be associated with significant weight gain, which may then affect sleep-disordered breathing.
Medications
I use medications for behavioural issues sparingly and only after trying other supportive measures. Most drugs can cause significant side effects, and managing these can be tricky. However, children who do not respond to therapy might benefit from medications, including antianxiety drugs. But be aware that some medicines can initially worsen symptoms, and children will require close supervision because of the risk of increased self-harm and suicidal thoughts.
I focus on sleep optimisation, including considering melatonin, early in treatment. It’s important to understand that children respond differently to medications, and a few trials at varying doses and types of medications may be necessary before finding what works best for the child.
Challenges
There are several challenges in managing children with Autism. Children with autism may not tolerate several medications and can experience adverse effects. Ex-stimulants can increase aggression when prescribed for co-existing ADHD.
The definitions are based on social norms, and children who don’t fit into that norm are classified as on the spectrum. However, philosophically, are humans able to define what normal is?
Disclaimer: The matter in this article is only for educational purposes. The diagnostic process in Autism and its management is complex and requires an assessment by an experienced clinician to arrive at a diagnosis and develop a plan. The content doesn’t replace advice from your trusted medical practitioner.
Resources that inspired the article
Krishna Jadav Carle. What’s my colour on the spectrum? 2025