bubble_chart Overview

Infantile autism is a developmental disorder that occurs in early childhood, characterized by impaired interaction with the external world (including parents). Its main manifestations include deviations or delays in the development of various psychological functions such as social interaction, language and motor behavior, attention, and perception.

bubble_chart Etiology

The cause remains unknown. Many scholars abroad have conducted extensive research from various perspectives, including family characteristics, social psychology, physiological anatomy, biochemistry, and genetics, but no definitive conclusions have been reached.

(1) Social Psychological Factors: It is believed that family factors play a certain role in the onset of the condition. The parents of such patients are often intelligent, highly educated, and introverted in personality. They frequently exhibit obsessive-compulsive traits, excessive anxiety about child-rearing, and a lack of warmth, which may contribute to the development of the disorder. However, this theory lacks sufficient evidence.

(2) Biological Factors: A higher proportion of children with this condition also experience epilepsy (10%–15%), and abnormal EEG findings are more common. Pneumoencephalography studies have revealed that many autistic children exhibit enlargement of the left frontal horn, suggesting the presence of mesial temporal lobe lesions, though the significance of this remains uncertain.

(3) Generation and Transformation Factors: Research has found elevated levels of dopamine and serotonin in affected children, but these findings lack specificity.

(4) Genetic Factors: Some studies indicate that autism is more prevalent among siblings of affected children compared to the general population. It has been confirmed that the concordance rate is higher in monozygotic twins than in dizygotic twins, suggesting a genetic predisposition in some cases. However, other reports show low concordance rates, making the genetic basis insufficiently supported.

Currently, many scholars hypothesize that some form of damage may occur at a certain stage during development, from fertilization to birth or shortly after. However, the nature of this damage remains unclear.

bubble_chart Clinical Manifestations

This condition is not uncommon, with 2 cases per 10,000 children in Germany, 8–10 in Canada, 13–16 in Japan, and 4–5 in the United States. Few cases have been reported in our country, which is related to insufficient awareness of the disorder.

The condition manifests early, potentially at birth, making it difficult to establish connections with others. However, onset typically occurs between 2–3 years of age. It is more common in boys than girls (3–4:1).

Clinical manifestations are diverse, with the following being the primary features.

(1) **Impaired Social Interaction** Affected children lack social engagement and emotional connections. They show no attachment to family members, do not engage in social smiling, and fail to distinguish between familiar and unfamiliar people.

Such children may exhibit extreme isolation even in infancy, showing no affectionate attachment to their parents and never clinging to them. In interactions, they avoid eye contact and cannot use gaze to express needs or emotions, let alone understand others' feelings. Studies confirm that while these children can recognize objects, they are unable to perceive human emotions (e.g., happiness, sadness, fear).

Children with autism struggle to form emotional bonds with those around them and rarely play with other children. Their relationship with parents may improve slightly during adolescence, but they remain socially inept and unresponsive to others' interests and emotions.

(2) **Language Impairment** After onset, language typically diminishes gradually, sometimes leading to complete muteness. Due to deficits in "inner language," they often fail to use or understand gestures and common social phrases (e.g., saying "goodbye" when parting). Nearly all affected children exhibit poor language comprehension and cannot interpret or utilize facial expressions, body movements, postures, or tone in social interactions. Abnormal speech patterns are common, such as echolalia, repetition, imitation, and pronoun reversal. They lack abstract concepts, and their thought processes tend to be obsessive, limited, and impoverished, resulting in a lack of imagination and fantasy.

(3) **Sensory Regulation and Motor Dysfunction** Children exhibit various sensory regulation disorders, characterized by either under- or over-reaction to external stimuli. They may ignore instructions or questions from adults, appearing "to look without seeing and hear without listening." To heighten sensory stimulation, they may engage in behaviors such as rubbing, flicking or hitting their ears, grinding teeth, scratching, or striking objects. Seeking vestibular stimulation, they may rock, sway, or rotate their heads. Conversely, some display sensory hypersensitivity, such as anxiety in response to certain sounds. The same child may alternate between sensory numbness and hypersensitivity.

Most children are hyperactive, often running instead of walking or tiptoeing. When stationary, they may hyperextend their necks and backs or adopt unusual postures.

Their behavior is ritualistic and compulsive, stubbornly adhering to fixed routines and resisting any changes. They exhibit a strong desire for environmental consistency. Some develop unusual attachments to specific objects (e.g., small items), carrying them constantly and reacting with intense distress or anxiety if they are removed.

In addition to the above primary symptoms, most affected children exhibit varying degrees of intellectual disability, and some experience epileptic seizures. A few may display isolated precocious abilities or savant skills—the so-called "idiot savants."

bubble_chart Diagnosis

The following diagnostic criteria are for reference.

(1) Onset usually occurs before the age of 3.

(2) Impairment in social interaction must include two of the following:

1. Inability to use eye contact, facial expressions, gestures, or postures for communication.
2. Inability to establish peer relationships with other children.
3. Does not seek support or comfort when encountering setbacks. Also does not offer support or comfort to others when they face setbacks.
4. Unable to share in the joy of group activities.

(3) Language impairment must include two of the following:

1. Delayed or absent speech development, such as not babbling, with a tendency to use gestures or other forms to replace verbal communication.
2. If some speech functions exist, there is a lack of active or sustained verbal communication.
3. Stereotyped and repetitive use of certain words or idiosyncratic use of language.

(4) Abnormal interests and activities must include one of the following:

1. Stereotyped and narrow interests.
2. Unusual attachment to certain objects.
3. Compulsive engagement in specific ritualistic behaviors.
4. Stereotyped and repetitive movements or postures.
5. Excessive focus on non-essential features of objects (e.g., their smell, surface texture, or the noises they produce).
6. Resistance or refusal to accept any changes in personal living environment.

(5) Exclude infantile dementia and childhood schizophrenia.

The Clancy Behavior Scale (Table 24-1) can be used for screening infantile autism.

Table 24-1 Clancy Behavior Scale
Filled by: Relationship to the child:
The table lists 14 child behaviors. Please read carefully and check the box on the right (use √) based on your child's behavior in the past month. Do not omit any items.

Behavioral Manifestations Never Occasionally Frequently

1. Difficulty playing with others
2. Does not respond to sounds, as if deaf
3. Strongly resists learning, such as refusing to imitate, speak, or perform actions
4. Ignores danger
5. Cannot tolerate changes in daily routines
6. Uses gestures to express needs
7. Laughs for no apparent reason
8. Dislikes being hugged
9. Constantly moving, unable to sit still, excessive activity
   10
10. Avoids eye contact, does not look at others' faces
11. Excessive attachment to certain objects
12. Fascinated by spinning objects
13. Repeats odd movements or play behaviors
14. Indifferent to surroundings

bubble_chart Treatment Measures

[Treatment]

primarily involves special education and behavioral therapy.

(1) Reducing family distress and boosting parental confidence are the foundation for initiating treatment. To ensure parental cooperation, it is essential for parents to understand the nature of the condition. Parents should be encouraged to face reality and eliminate feelings of anxiety, regret, and despair, thereby creating a relaxed family environment. A cheerful and harmonious family atmosphere has a positive impact on the improvement of the child's condition. If possible, training and therapy can be conducted in special schools during the preschool and school-age stages.

(2) Special education is crucial for promoting normal development in children, broadening their learning abilities, reducing stereotyped and rigid behaviors, and eliminating non-specific maladaptive behaviors through organized and planned instruction in a controlled environment. The techniques used in special education, such as visual-object teaching, gestures, postures, communication and conversation, play, emotional engagement, music, physical therapy, and art, should be tailored to the child's cognitive impairment level—this is known as individualized education.

To facilitate language development and the learning of new things in children with autism, some scholars have proposed the following educational strategies (Table 24-2) based on the child's specific issues and needs.
Table 24-2 Educational Strategies for Children with Autism
Strategies for Promoting Language Analysis
Needs Problems in Autistic Children Educational Strategies

1. Basic language skills Lack of ability Directly teach language appropriate to their ability
   Other communication methods Promote social development
   Ignores others, lacks initiative
2. Conversation Lacks response Planned interaction
3. Social language communication Unable to express existing language Teach appropriate language Reinforce appropriate language Emphasize the practicality of language education Strategies for Promoting Learning of New Things Analysis Lacks initiative in learning Structured learning environment 1.

Attention cues Break down learning steps Overly selective attention Avoid unnecessary prompts Other deviant behaviors interfere Eliminate interfering behaviors Emphasize practical materials in natural environments 2. Generalization ability Ability deficits Avoid rigid teaching environments Planned generalization lessons Structured lesson plans 3. Understanding Memorizes without comprehension Evaluate learning outcomes Use appropriately challenging materials 4. Frustration tolerance and retry Gets angry or gives up when frustrated Increase frustration tolerance

Children with autism have poor language-learning abilities, so they should be taught language within their capacity. If oral language skills are lacking, gestures or postures can be taught as alternatives. For those struggling with social language communication, in addition to teaching appropriate language, reinforcement is necessary. The method involves reinforcing the child’s context-appropriate language using operant conditioning. Due to their lack of initiative in learning, overly selective tendencies, and interference from deviant behaviors, these children often struggle to focus on the content provided in teaching materials. Therefore, learning steps should be clearly broken down, avoiding haste, and a structured learning environment should be provided to enable step-by-step learning. Unnecessary prompts should be avoided, and interfering behaviors should be eliminated. Play plays a significant role in education because it is an activity form most suited to children's psychological characteristics. It reflects the inner world of the child, allowing doctors to understand the child's condition through careful observation. Play can also release suppressed emotions, serving as psychological疏导, and thus has therapeutic effects. Additionally, play can foster positive personality traits (such as discipline, camaraderie, etc.) and address chaotic, impulsive behaviors and social withdrawal.

To help children with autism establish emotional connections with those around them, the "doll" game can be played. The mother holds the "doll" in her arms, pats it, and kisses it. She talks to the "doll," and the child imitates the adult's actions, doing the same. Children with autism often avoid eye-to-eye contact, so the adult should say to the child, "The doll is pretty, look at the doll's face." Through the "doll" game, the child can develop an interest in the "doll" and transfer their affection to their parents. Playing with peers of similar age can enhance social interaction and establish appropriate behaviors. Experience has shown that improvements in a child's behavior during play can trigger a chain reaction, leading to progress in other behaviors as well.

(3) Behavioral Therapy The primary method used is operant conditioning, where rewards are given when the child exhibits good behavior to reinforce that behavior. For meaningless or inappropriate actions, "punishment" is applied to extinguish them. Rewards can take various forms, such as candy, toys, clothes, or a trip to the zoo, depending on the situation. Parental terms of endearment, affection, and kisses can also serve as rewards to reinforce positive behavior. "Punishment" does not mean physical discipline but rather the withdrawal of previously promised rewards. Sometimes, ignoring the child's inappropriate actions or redirecting their attention to other things can also help extinguish undesirable behaviors. Here’s an example: Autistic children often scream to express needs, engage in stereotypical rocking movements, or show great interest in swinging. Parents can instruct the child to raise their hand instead of screaming to earn the privilege of swinging (reinforcement). After repeated training, the child learns to use the voluntary hand-raising gesture to communicate their needs (this is part of gesture language training). Leveraging the child’s tendency to imitate speech, language reinforcement training can be conducted. For instance, show the child an apple (green or red), let them smell it (fragrant) and touch it (round) to deepen their understanding of the apple. Then, ask the child to repeat the word "apple" after an adult. When the child says "apple" or a similar sound, give them a taste (sweet) as reinforcement.

Continuous reinforcement is the key to the success or failure of this behavioral therapy. Behavioral therapy has been widely applied in special education.

(4) Drug Therapy The following medications may be tried.

1. Haloperidol This Yaodui reduces hyperactivity, stereotyped movements, irritability, dysphoria, and emotional instability, while improving social withdrawal and learning abilities. Due to varying drug sensitivities, the dosage differs among individuals, but most children generally require a small dose: 1-2 mg daily.

   2. Fenfluramine Its efficacy remains unconfirmed, so caution is advised.

2. Naltrexone This can increase speech and reduce social withdrawal and stereotyped, repetitive movements. Dosage: 0
3. 5-2 mg/kg/day. Side effects are limited to grade I drowsiness, with no adverse effects on ECG or liver function.

bubble_chart Prognosis

The prognosis of this disease is poor. Long-term follow-up of affected children has found that about two-thirds of patients remain severely disabled by adulthood, with only a few individuals able to engage in certain social activities and work.

If autistic children have a higher IQ (IQ > 70) and can use communicative language by the ages of 5–7, the prognosis is best. If the initial IQ is below 50 or 60 and communicative language has not developed by age 5, the prognosis is poor and may lead to lifelong disability. Conversely, there is a 50% chance of achieving good social adaptation by adulthood, but only 1% or 2% can become "normal individuals."

About one-fifth of autistic children develop epileptic seizures during adolescence, which is more common in those with grade III intellectual disability. Epileptic seizures can further worsen the prognosis.