Social Interaction and Communication Challenges
The main difficulty faced by children with autism is socialising and communicating with others.
Young children with autism are often described as 'being in their own world' – preferring to be alone most of the time with very little interest in others. Their responses to external social engagements are poor and inconsistent. The younger children may use people as a "tool" to obtain certain things, e.g. pulling an adult's hand to the object he wants without a word or glance, rather than using gestures or words.
Some older and more abled autistic children may appear sociable. However, they lack the social 'know-how', have difficulty registering social cues, and often end up being inappropriately sociable or even offending. Understanding and expressing emotions do not come naturally to them. Typically, they interact better with adults they are familiar with than their peers.
Most children with autism would have some degree of speech and language delay or difficulties. Approximately 40 per cent of children with autism do not acquire speech at all.
Younger children often present with delayed speech. Some children may be fascinated and love to recognise and read letters and numbers out aloud and thus appear to be able to speak. However, they are paradoxically unable to communicate their needs using common daily vocabulary. In the early stage of language development, pronoun confusion is not uncommon. For example, saying “carry you” instead of saying “carry me” when requesting to be carried. Some children echo what is being said to them i.e., echolalia, instead of answering any question appropriately.
More abled children with autism may have 'hyperlexia'. They may recite phrases from television commercials, computers and encyclopaedias ('scripted language'), but cannot use the same words to communicate meaningfully or effectively in daily interaction. He may be able to read complex words and passages but do so with little understanding of the meaning or context. They may also use illogical words (neologism), or use some words repetitively (verbal perseveration).
Among those who are older and eventually learn to speak fluently, they may still have difficulties with the semantics and pragmatics in language. They tend to be literal in their understanding and cannot 'read between the lines'. There is also difficulty with understanding abstract concepts and making inferences. Hence they tend to struggle with appreciating humour, sarcasm, metaphor, or other nuances in communication or learning.
Using facial expressions and symbolic gestures (e.g. waving bye-bye) is generally lacking, often known as 'poor symbolic communication'. Eye contact is notably absent or poor. At a younger age, this may manifest as poor social referencing and pointing skills. Eye contact tends to improve with age but is usually incomparable to their peers. If present, body language can be awkward or inappropriate due to lack of social understanding and modulation of behaviour.
Lack of Imaginative Play and Repetitive Behaviour
A child generally learns to play imaginatively from the age of 2-2½ years. This is usually demonstrated by play with toys such as 'masak-masak' (cooking toys), toy guns and doctor sets. The child with autism has poor imaginative skills and often plays in an unusual way. He may spin an object or play in a repetitive manner (e.g. lining up cars and blocks). Some children with autism may appear to play imaginatively but often in a learnt or restricted manner (e.g. always with the same “storyline”).
Abnormal Responses to Sensory Stimulation
Children with autism have an unusual level of sensitivity and responses to sensory stimuli. Within an individual, there can be varying patterns of sensitivities and responses to different stimuli.
For those who are hypersensitive, the underlying issues are in "filtering out" extraneous stimuli and modulating their behaviour accordingly. For example, they may notice noises in the environment that are imperceptible to others (e.g. air-con). Normal environmental noises can also be excruciatingly loud or bring about pain and discomfort to these children. In children who have difficulties expressing themselves, this may then be exhibited as a tantrum or an increase in repetitive behaviours.
On the other hand, some children may have a higher threshold to registering sensation from the environment. This may exhibit as excessive seeking behaviour for sensation, e.g. fascination with lights or colours, pre-occupation with tapping of surfaces, fiddling with objects, smelling unusual objects, spinning themselves without getting dizzy. Coupled with the general lack of social modulation, such behaviour in a public situation can be embarrassing and frustrating for their care-givers.
Other Associated Differences in Development
A child with autism may have relatively normal motor skills; however, many are clumsy and have difficulties participating in physical games and activities. Some have poor fine motor skills that result in poor handwriting skills.
Skills may appear at the appropriate time and then disappear, a characteristic known as 'regression of skills'. For example, a child may have normal language development then lose their earlier skills at a later age. Such regression may be an indication of underlying genetic or metabolic abnormalities, or onset of subtle neurological problems, e.g. seizures. If regression is present, there should be a search for secondary causes of autism.
Some children with autism have exceptional talents and specialised skills, often referred to as savant skills. Though rare, such skills should be nurtured if present, as they may represent possible vocational opportunities in future.
While the autistic child may manifest varying degrees of the symptoms as described above, not all the features listed may present in one single child. However, all autistic children will have difficulties in the key areas of social interaction, communication, imaginative play, repetitive behaviour and sensory processing.
Does My Child Have Autism?
Autism is often detected in early childhood when parents seek help for delayed speech and language development in their child. Typical age of presentation is around 2-3 years old, and a definitive diagnosis is usually made around the age of 3. Autism affects boys 4 times more than girls. Clinical presentation in female children with autism tends to be more subtle, often leading to delayed diagnosis and access to support services.
If your child has the symptoms as described above and you suspect he has autism, you may want to make an appointment for your child to be assessed at the Department of Child Development (DCD) at KK Women’s and Children’s Hospital. During the first visit, an inter-disciplinary team of paediatricians, nurses and psychologists will conduct a general developmental screening assessment. If further diagnostic evaluation and management for autism are needed, your child will be referred to the ASD service within DCD. The ASD service comprises a team of developmental paediatricians and allied health professionals (e.g. psychologists) who will coordinate appropriate diagnostic assessments to determine diagnosis, level of functioning and needs. The ASD team will also assist in accessing short-term early intervention services within DCD (e.g. speech and language therapy, occupational therapy, physiotherapy, educational therapy), as well as long-term early intervention programmes in the community. In addition, the ASD team will journey with you to make appropriate decisions regarding educational placement, such that your child’s potential is maximised and his needs are met. At DCD, parents are seen and valued as equal partners, and your participation at every step of the journey will make a big difference in your child’s life.
Many resources about autism are available in the community. You can become a member of the Autism Association (Singapore) (AAS), or attend training courses and access resources at the Autism Resource Centre (Singapore) (ARC):