46 Chapter 4
determine whether autism reflects the co-occurrence of the three features
by chance, or whether the combination is more common than would occur
by coincidence.
Characteristic features
Childhood autism is defined by theearly onsetof symptoms in three
domains:
1 Social impairment
2 Communication impairment
3 Restricted and repetitive activities and interests.
Social impairment
These concern the quality of reciprocal interactions with others. The
archetypal young child with autism is aloof, with poor eye contact, shows
a lack of interest in people as people (though they may be interested in
people as tickling machines, biscuit dispensers, etc.), and fails to seek com-
fort when hurt. If social interest subsequently develops, as it does in the
majority of children with autism, problems persist in social responsiveness,
reciprocity and the capacity for empathy. There are difficulties adjusting
behaviour according to the social context, and problems recognising other
people’s emotions and responding appropriately. Attachment to parents is
not unusual, and the child may be affectionate (or even over-affectionate),
although he or she is more likely to initiate cuddles than to accept cuddles
initiated by his or her parents. Nonetheless, a substantial proportion
of individuals with autism make secure attachments to their parents.
Social interactions are on the child’s terms – adults and much younger
children typically adjust better to this than children of the same age.
Interactions with peers are generally very restricted. Even among older
high-functioning individuals with autism, a limited ability to form close
friendships (involving mutual sharing of interests, activities, and emotions)
is probably the most sensitive index of residual social impairments.
Communication impairment
This affects comprehension as well as expression, and gesture as well as
spoken language. Babble may be reduced. Good studies carried out at a
time when autism was less commonly recognised suggested that roughly
30% of individuals with classical autism never acquired useful speech. The
proportion may be lower nowadays since the concept of autism has broad-
ened and milder cases are now more widely recognised, thereby diluting
individuals with a poor prognosis in a much larger pool of individuals with
a better prognosis. Among those who do acquire speech, the milestones are
typically markedly delayed. A minority of individuals with autism acquire
single words and even phrases at the normal time but then lose these skills
again. Speech, if it emerges, is typically deviant as well as delayed. Possible
abnormalities include: immediate or delayed parroting of words or phrases