Recognising Autism Spectrum Condition in Children
Our film explains how to recognise and help a child with autism spectrum condition.
The film focuses on children whose autism may not be readily apparent, especially girls as they are particularly good at ‘masking’ symptoms. As the spectrum is so varied, this Fact Sheet is intended to cover a wider range of issues and provide more in-depth information than was possible in the film.
Autism spectrum condition (ASC), is the preferred name for what is formally known as autism spectrum disorder (ASD). ASC is not technically a mental health disorder; it is a neurodevelopmental condition. However, as 70% of children with ASC develop at least one co-occurring mental health issue, and 40% of these will develop more than one, early recognition is key.
ASC affects three main areas of functioning: communication, social interaction and behaviour.
Autism is not an illness; it is a spectrum condition that will vary across each area and therefore affect each person differently. However, for a diagnosis to be considered, the overall impact on daily functioning and quality of life must be significant. There also has to be evidence of the condition in the child’s early developmental period. However, in more able children the social communication differences may not be apparent until much later on in life.
By providing early support for ASC the aim is to mediate against or reduce the likelihood of the child subsequently developing anxiety and depression through unmet need. Furthermore, as children on the spectrum are at increased risk of epilepsy and other neurodevelopmental issues, enhanced awareness of the condition is essential.
What are the signs and symptoms of ASC?
The earliest sign of autism is often a difference in the way that language develops. Some children are delayed in starting to speak, others may babble and use single words, before regressing and losing their skills. Some children may never learn to speak at all.
Some children develop language but do not use it as a means of communicating with others. For example, they may parrot, or mimic speech heard on television. Other children may repeat set phrases or have unusually formal language that sets them apart from other children. Some children may adopt accents or talk in a monotone.
A number of children may develop language much earlier than their peers and display an advanced vocabulary. Although articulate, they may tend to talk at, rather than with, their parents or friends. Some children can speak but may appear selectively mute in situations where they are less comfortable. Other children will talk too loudly, without any awareness of their volume.
Non-verbal communication can also be affected. Some children on the spectrum may avoid eye contact or have difficulty interpreting facial expressions or body language. Their gestures tend to be reduced or unusual. For example, some children do not point or wave effectively, and struggle to co-ordinate eye gaze with gesture.
Contrary to the stereotype, children on the autism spectrum may be just as interested in socialising and making friends as anyone else.
Some children are socially withdrawn and will avoid mixing with other children. They may watch from the periphery, rather than join in with a social group or they may prefer to mix only with adults. Others are unreserved and will treat strangers as trusted adults or treat teachers as their peers. Some children will only ever interact on their own terms, ignoring bids for social attention from other people.
It can be hard to read the mood or internal state of a child with autism spectrum condition. They may appear happy, when upset, or have the wrong facial expression for the situation. Many children appear neutral, unless experiencing an extreme emotion, such as anger or joy. For some children on the spectrum it can be hard to register their own emotions or bodily sensations. They may not realise they are feeling stressed or hurt until they are overwhelmed and have a meltdown.
Children with ASC may only see their own point of view and so feel that they are being treated unjustly. Conversational turn-taking might be less developed and revolve around the child’s particular needs or special interests. They can be literal in their interpretation of language and in their adherence to rules. Parents note that often the child can make up their own rules and get upset when others do not stick to them. This lack of flexibility contributes to peer rejection and social isolation.
These issues may not be apparent early on in primary school but as the child progresses through their education, peer difficulties become more marked.
Children on the spectrum will often respond negatively to changes in environment or routine. An extreme emotional outburst could be triggered by toys being moved unexpectedly, different foods making contact on the same plate, or a road-work diversion changing the usual route to school. Some children insist that family members sit in the same chair each day or enter the car in a particular order. Often misunderstood as spoiled, this behaviour stems from the acute anxiety experienced when the situation does not look or feel right to the child.
Sensory sensitivities can also contribute to behaviour differences. Some children are averse to certain noises, smells, lights, tastes or textures. Their diet may be restricted to “safe”, or predictable foods. Hectic or crowded places can feel overwhelming. Some children seek respite in low arousal environments and resist moving from one place to another. In contrast, some children on the autism spectrum actively seek out sensory experiences, such as tight hugs, soft fabrics and familiar songs, which can be soothing.
Children on the autism spectrum often play in an inflexible, rule bound way. Although some may have an excellent imagination, they may struggle to let others contribute to their games as they have a fixed idea about how each game should look or how it should unfold. Any change to the expected plan or appearance of the game can trigger anxiety. Other children lack a social imagination and can only interact in a concrete logical and factual way.
Emotions may be accompanied by hand flapping, pacing and rocking or tics when the child feels excited or distressed. Stereotyped or repetitive moments are a key feature of the condition.
Many children on the autism spectrum have a history of restricted or obsessional interests. For example, parents often mention that their child has a particular passion for cars, trains or dinosaurs. Some interests will be typical for the child’s age or gender but may be all-encompassing, whilst other interests may be unusual and unique to that child. Regardless of the subject matter, it is the intensity and duration of the special interest that differentiates children on the spectrum from their peers.
The features associated with autism, including cognitive rigidity, pervasive anxiety and resistance to change, can have a huge impact on the quality of family life. However, in more able children behavioural challenges do not necessarily become apparent in school until the later years of primary education.
A common theme is that children on the spectrum behave differently in different settings. For example, they may appear fine in school but become extremely distressed at home. Other children are calm and relaxed at home but have frequent meltdowns in the class or playground.
How do I get a diagnosis for my child on the NHS?
In the early years
If your child is delayed in meeting developmental milestones, seems socially withdrawn, resists different tastes and textures, or engages in challenging behaviour, the first step would be to talk to your health visitor or GP. If concerned, they can make a referral to Community Paediatrics for a developmental assessment and review of the child’s health. If that process confirms the presence of social communication differences, formal diagnostic assessment will then be scheduled.
If your child is not talking by the age of two years, the health visitor will make a referral for speech and language therapy. The speech and language therapist will also be able to advise about whether further neurodevelopmental assessment is needed.
In the primary school years
If your child is displaying difficulties with behavioural regulation, peer interaction, an insistence on routine and resistance to change, the first step would be to talk to the school and to the GP. If concerned, they will make a referral to Child and Adolescent Mental Health Services for assessment and support.
Getting an independent diagnostic assessment
If the child is increasingly anxious or presenting with extremely challenging behaviour the wait for an NHS assessment can feel too long.
If seeking a private assessment, the advice would be to work with a multi-disciplinary service that follows NICE guidelines. This should ensure that any diagnosis is recognised and follow-up provided by NHS services as needed.
Ideally, a diagnostic assessment should involve a covert school observation or liaison with teaching staff, an assessment of the child’s learning skills and a medical review, as well as the gold standard measures for assessing autism spectrum condition. Recognised measures include the Autism Diagnostic Observation Schedule (2nd Edition), The Autism Diagnostic Interview (Revised edition), The Diagnostic Interview for Social and Communication Disorders, and the 3Di (The developmental, dimensional and diagnostic interview: a new computerised assessment for autism spectrum conditions).
A comprehensive multidisciplinary assessment provides essential information about both the child’s strengths and difficulties. Treatment and support can then be tailored to the particular needs of the child and family.
Following a diagnosis, what options are there for helping the child and family?
Depending on the age and particular needs of the individual child and family, the following services may be available:
- Speech and Language therapy to promote spoken language, joint attention and social communication skills
- Occupational Therapy to address sensory processing difficulties that can impact on attention and behavioural regulation
- Paediatric advice for children who require assistance with sleeping, toileting or co-existing medical problems
- Dietary support and behaviour advice for children who restrict their food
- Clinical psychology to design and implement tailored treatment approaches, for example, modified cognitive behaviour therapy, social skills training, specialist parenting programmes and sibling support
- Psychiatric input may also be warranted, if a trial of medication is required.
- An educational psychology assessment to address co-occurring learning differences and any problems in accessing education
- Special Educational Needs (SEN) support in school and advice about applying for an Education Health Care Plan, with advocacy from the local Special Educational Needs and Disabilities Information Advice and Support Service (SENDIASS)
- Support from social services and advice about eligibility for benefits and respite care
- Access to specialist parenting courses, and support groups for parents and siblings
- Signposting to accredited websites, charities and literature by the diagnostic team.
Dr Lisa Honeyman
Principal Clinical Psychologist and Consultant with Lorna Wing Centre for Autism (National Autistic Society)
Dr Elaine Clark
Consultant Paediatrician in Neurodevelopment
Great Ormond Street Hospital