Autism Spectrum Disorder

April is Autism Awareness Month. With approximately 72,500 people in British Columbia diagnosed with autism spectrum disorder (ASD) in 2023, plus an unknown number of people not yet diagnosed, odds are very high that you will treat several people with ASD this year. With a few simple adjustments to your usual approach and general treatment plan, you will be able to provide optimal care to this population.

Autism is a developmental disorder that affects how a person experiences the world and influences how they communicate and behave. Characterized by challenges in social interactions, communication, and repetitive behaviors, the severity of these symptoms is on a spectrum and may exist in any variety of combinations. It’s important to remember that each person is a unique individual despite sharing a common diagnosis.

The following list includes common behaviours and presentations you may notice in a person with autism. This list has been edited for the context of EHS.

• Reduced eye contact
• Differences in body language
• Lack of facial expressions
• Repeating gestures or sounds
  • Stereotypies: hand flapping, rocking, vocalizations
  • Echolalia: repeating what you say, often without understanding and involuntary. Is often a stress response and done to self-regulate/comfort. Does not mean they do not have functional communication.
• Sensory sensitivities – if overwhelmed, may become dysregulated and may lead to acting out
  • Common sensory sensitivities are sound (too loud), lights (too bright), general busyness (chaotic scene, fast movements around the person)
  • Difficulties with transitions (moving from one activity to the next)
  • Many feel physical sensations very differently (usually higher tolerances)
  • Pain – very high pain tolerance!
  • Temperature extremes – high temperature tolerance!

A hallmark characteristic of autism is challenges with communication. There are three distinctly separate classifications of verbal communication, with 25 to 35 per cent of people with ASD not having functional communication in any form (ability to express basic wants and needs).

• Nonverbal – unable to communicate with spoken words, may or may not be able to vocalize sounds.
• Minimally verbal – a few words (< 30 to 50), may be hard to understand, usually not considered functional
• Verbal – varying degrees of ability, at minimum has functional communication

There are a few alternatives to verbal communication. Those with elevated skills may learn keyboarding and communicate through typed words. For those with more challenges, Augmented Communication Devices (ACD) are available, with PECS and Talkers the most common.

• Picture Exchange Communication System (PECS) uses a wide variety of small (1” sq) laminated pictures are organized by language categories (verbs, nouns, etc.) and attached to a page with Velcro. The person then takes pictures and puts them on a separate sheet to construct a sentence or message. The picture library may be stored in a large binder (at home), a smaller photo album when in the community., or even a few laminated 4” x 6” cards on a ring. Although some of the pictures have written words on them, a limitation of this method is the other person’s ability to understand the pictures. The pictures are universal and are used on other types of ACDs.
• Talkers use one of two available apps (Lamp, TouchChat) on an iPad. Using the same types of pictures as PECS, the person touches a picture on the screen to bring up another page, eventually getting to the word they want. When selected, the word goes into the top bar (like address bar) and when touched, the words are spoken by the iPad. There are numerous configurations and layers available.

What Autism is Not

• Autism is not a disease – the cause is unknown but suspected to be genetic. An interesting fact is Autism is increasingly being considered its own community much like the Deaf or the Blind.
• Autism is not curable – interventions are used to support the person with overcoming challenges and developing strengths.
• Autism does not equal intellectual disability.
• Nonverbal does not equal intellectual disability.

Comorbidities

• Gastrointestinal Issues – up to 85 per cent (chronic constipation, diarrhea, and abdominal pain)
• Anxiety Disorder – 84 per cent (including generalized and social anxiety, and OCD)
• Sleep Disorders – 50 to 80 per cent of children with autism, negatively impacts general health, ability to self-regulate, and behavior
• ADHD – 50 to 70 per cent
• Seizure Disorder – 35 per cent (compared to one per cent in general population)
• Intellectual Disability – 30 to 40 per cent
• Obesity – 30 per cent of children with autism (compared to 13 per cent in general population)
• Nonverbal or Minimally Verbal (no spoken functional communication) – 25 to 30 per cent
• Depression – 26 per cent (compared to seven per cent in general population)

What Can You Do?

The following recommendations do not override critical treatments or care. When the situation and time allows, a few simple adjustments could help a person with autism feel more comfortable and therefore more cooperative.

• Reduced eye contact – if the person is not holding eye contact, look over their shoulder when talking.
• Repeating gestures – if practical, do not try to hinder these movements. They are often done to self-regulate.
• Echolalia - if you notice they are repeating everything you say, remember this is often an involuntary stress response that may be used to self-regulate or sooth. Do not continue questioning them. Consider time and space, if possible, and ask an accompanying adult the questions.
• Sensory sensitivities – offer ear protection (industrial earmuffs/headphones), sirens off, or dim cabin lights. If they have communication, ask them what they need. Some people crave deep pressure to regulate; consider offering tight packaging or other ways to apply generalized pressure. If possible, remove the person from a chaotic scene as soon as practical.
• Transitions – tell them what you are doing before you do it and give them time to process it. Setting a timer on your phone or watch may help, even if for only a minute. Or tell them that after you put ____ away, it will be time to drive to the hospital. Many children with ASD are taught “First this, Then that” phrasing. For example, “First I have to put my bag away, then we will drive to the hospital”.
• Physical sensations – be aware of higher tolerances for pain, temperatures, etc.

Like everyone, communication is the key. Meeting them where they are at and adjusting your way of communicating to match theirs will promote cooperation. Below are some tips:

• Wait for an answer to your question. When you think you have waited long enough, wait more.
• Do not rephrase the question as doing so just forces them to decode a new message.
• Use plain, simple language and short sentences until you confirm their ability to communicate effectively.
• One sentence or simple question at a time.
• If you see an iPad near or on the person, take it with you. It is their voice!
• If you notice a binder, photo album, ring with laminated pages, take it with you. This is their voice!

Resources

• Autism’s Clinical Companions: Frequent Comorbidities with ASD | Children's Hospital of Philadelphia
• Co-Occurring Conditions and Autism - Autism Research Institute
• Autism and Intellectual Disability Explained
• What Percent of Autistic Adults Are Nonverbal? - Biology Insights
• Language and Speech Characteristics in Autism- Dovepress Medical Press
• Receptive language and receptive-expressive discrepancy in minimally verbal autistic children and adolescents - PMC
• Autism Rates by Country 2026
• Autism Surveillance System in Canada
• FAQs - AutismBC
• Rethinking Stereotypies in Autism - PMC