Autism Spectrum Disorder (ASD)

Autism spectrum disorder (ASD) is a complex and multifaceted central nervous system (or neurodevelopmental) disorder. The classic symptoms include deficits in social communication, a restrictive range of interests, and repetitive behaviours.

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), ASD is characterized by:

a. Persistent deficits in social communication and social interaction across multiple contexts, including difficulties with verbal and nonverbal communication, such as:

• Struggling to initiate or maintain conversations
• Difficulty understanding tone, nuance, and context
• Challenges with eye contact, facial expressions, and body language

b. Restricted, repetitive patterns of interests or behaviours, such as:

• Intense focus on specific topics or activities
• Repetitive movements or actions (e.g., hand flapping, rocking)
• Insistence on strict routines or rituals

c. Symptoms must be present in the early developmental period, although they may not become fully apparent until social demands exceed an individual's limited capacities or may be masked by learned strategies in later life. This means that some people may not receive a diagnosis until they encounter challenges in social, educational, or occupational settings.

d. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning, impacting daily life and relationships. This emphasizes that ASD symptoms must have a substantial impact on an individual's ability to function and participate in various aspects of life.

These diagnostic criteria provide a comprehensive framework for understanding and identifying ASD, taking into account the complexity and variability of the condition.

ASD is likely due to a combination of genetic and environmental factors during pregnancy, although it is difficult to pinpoint the exact causes in each person.

Over 700 different genes are implicated in ASD. There are also very rare genetic conditions that may cause ASD, such as fragile X syndrome, Rett syndrome, and tuberous sclerosis. These rare conditions may be identified by paediatricians when the affected individuals are toddlers, as they often present with other health problems. Children with Down syndrome have a higher probability of developing ASD as well.

ASD tends to affect boys 3-4 times more often than girls, suggesting mutations in the male gene (chromosome X) may be implicated. If a family member (e.g., parent or sibling) has ASD, there is also a higher chance of developing the disorder.

Other risk factors include premature birth and advanced parental age, as there is a higher chance of genetic changes (mutations) in the sperm and egg of older individuals. Maternal exposure to toxins and certain medications for epilepsy (such as sodium valproate) has also been associated with ASD.

There is no evidence to the myth that the measles, mumps, and rubella (MMR) vaccine causes autism.

Common early signs of autism in pre-schoolers include:

• Lack of eye contact
• Speech and language delays
• Communication difficulties
• Limited facial expressions
• Not expressing emotions
• Showing little interest in other children
• Not responding to their name at times
• Restricted narrow topics/objects of interests
• Repetitive behaviours

Yes, it is possible that their symptoms of autism are milder and not picked up by teachers and professionals. The more subtle signs of mild autism in school-aged children include:

• Difficulties communicating with others (either a lack of communication or having atypical communication patterns)
• Difficulties maintaining two-way conversation (conversation seems to be one-sided and difficult to direct)
• Tendency to use more words than needed in responses
• Misinterpreting conversations
• Consistently flat voice or strange intonation in voice (e.g. high-pitched)
• Lack of gestures / non-verbal behaviours
• Gestures are poorly integrated with verbal communication
• Difficulties making or maintaining friendships
• Emotional regulation difficulties
• Anxiety in social situations

This depends on many factors such as the child's social skills, cognitive ability, learning needs and behavioural support requirements. Each child's profile should be evaluated to determine the level of support needed.

If the child's cognitive ability is in the low-average to average range and the level of overall support can be met in a mainstream school, it is possible for the child to remain in a mainstream school. Nonetheless, additional professional support such as social skills training, behavioural and emotional management support may be required for the child to thrive in a mainstream environment.

In some cases, even in cases of mild autism, some children can benefit from a special education environment which better serves their social and emotional development needs.

Asperger's syndrome is a neurodevelopmental disorder characterized by:

1. Difficulties with social interaction and communication.
2. Restricted and repetitive patterns of behaviour, interests, or activities.
3. No significant delays in language development or cognitive development.
4. Poor social pragmatic skills (tend to use socially inappropriate language or speak inappropriately / out of context)

Asperger's syndrome used to be a separate diagnosis from autism, but under the DSM-5, it is now placed under the broader umbrella of Autism Spectrum Disorder. Compared to severe autism, individuals with Asperger’s syndrome have less severe symptoms, no language delay, and more advanced speech and language skills.

• Intake interview (1 hr): The assessment process starts with an intake interview with caregivers, to screen and collect relevant information about the child's difficulties. This session helps to verify the need for a full assessment and clarify the steps of the assessment process. If it is determined that a full assessment is not required because the child is very unlikely to have autism, the process ends here and we will recommend other forms of assessment and interventions.

• Diagnostic interview with parents (2 hrs): This is a semi-structured comprehensive interview with parents to review the developmental history of their child, track the presence of autism symptoms, and compare it with current behaviours.

• Assessment session with child (1-2 hrs): An autism rating scale is carried out alongside behavioural observations whereby the child is engaged in play or social activities specially designed to elicit and identify features of autism. Depending on the age and profile of the child, parents may or may not need to be present.

• Debrief (1 hr): After integrating and evaluating the assessment findings, a psychological report will be prepared. The findings, diagnosis (if relevant), and recommendations are shared with caregivers (with or without the child) during this session.

Children below 3 years old should see a paediatrician for autism assessment. The periodic developmental milestones checks, as recommended by Ministry of Health and concurrent to the childhood vaccination schedule, are very useful points for screening and for parents to voice any concerns about the child’s behaviours, language and social skills development.

Children, youths and adults with significant emotional or mental health difficulties along with autism symptoms, should see a psychiatrist for assessment of emotional/mental health concerns and treatment.

On the other hand, an educational psychologist can help do the following:

• Assess and diagnose children or individuals above 4 years old who are suspected to have autism.
• Carry out autism assessments as part of a multi-disciplinary team approach.
• Provide consultative advice to plan next steps, such as remediation support for existing difficulties.
• Provide inputs on the likelihood of autism and whether a detailed autism assessment will be helpful.
• Provide recommendations for educational support.
• Assess a child's cognitive abilities and adaptive skills to ascertain their learning profile and advise on appropriate school placement.
• Develop behaviour support plans and implement social skills training for a child with an autism spectrum condition.