**2. Diagnosis**

Diagnosis is still a problem with some diagnosticians still holding on to outdated concepts like Kanner's autism. Kanner's autism is very real but an extremely rare form of autism, and only a small minority of children meet the criteria for Kanner's autism. Fitzgerald et al. [1] showed that there were different prevalences of diagnosis, depending on which criteria were used:


This remains a problem, and it remains to be seen what the final diagnostic criteria for autism spectrum disorder will be. Currently, we use DSM 5 [2]. According to Baird et al. [3], about 25 per 10,000 met criteria for autism diagnosis based on

the autism diagnostic interview/autism diagnostic observation scale (ADI-ADOS), while the rate for current diagnosis which would be the autism spectrum disorder gave a rate of about 116 per 10,000. This means ADI-ADOS is missing over threequarters of patients who would now be described as having an autism spectrum disorder. It is commonly missed by professionals that the diagnosis of autism is a clinical diagnosis by an expert in the diagnosis of autism [4]. Missing autism spectrum disorder has catastrophic effects on the child themselves, the family and school.

Clearly, only those with higher IQ, the standard IQ necessary for university, will move on to a university. One of the most damaging aspects of the school life, which is almost pervasive and long lasting, is bullying. This leads to anxiety, PTSD, and depression in these children, as well as suicidal behaviour.

#### **3. Intervention**

It is critical that the quality of training that teachers and classroom assistants have is good. It is almost impossible for those in the classroom to work with children with autism without the clinical autism gestalt. Staff who have this correct sense of the world as seen by a child with autism do extremely good work, become fascinated with the topic and spend the rest of their professional life working with children with autism. Many of the children with autism are the most interesting children a teacher can have the privilege to work with. Many have special talents, and there is a need to build on these special talents and use them in the context of social interaction and building social skills. This will increase the chances of the child living independently and having occupational success later, sometimes which is something that is extremely challenging for persons on the autism spectrum, including those with a high IQ on the autism spectrum. The issues of parent and school relations are very challenging. Because of the nature of autism, both sides can have extreme difficulty seeing things from the others' point of view. Parent/ staff meetings will have to be twice as long, when the child has autism because of the difficulties of communication. It is not surprising that staff can feel persecuted and misunderstood because they are speaking on a different level to the parents. The child with autism requires special understanding on the part of the school to understand their difficulties. It is not surprising because of these difficulties that there are often threats of litigation or actual litigation, because of these interpersonal communicational problems.

Of course, it is very easy in these situations for both sides to feel misunderstood. It is sometimes helpful for an outside professional child psychiatrist/child psychologist to be engaged to deal with these difficulties. Children with autism and their autistic friends live in a culture in an autistic culture, and it is necessary for teachers to understand them. Teachers have to be aware of the family's and particularly the child with autism difficulty understanding emotions. It is not rare for more than one member of a family to have autism because it has such a high genetic loading. It is critical that teachers make reference to special autism services when the child is depressed, is very anxious or is making threats of killing themselves, which are far from uncommon. The relationship between the teacher and the outside autism professional will be critical to the child's success in school. Severe depression of psychotic proportions may need to be treated with antidepressants, and attention deficit hyperactivity disorder, which is so often co-morbid with autism, is often missed by child psychologists and child psychiatrists, and this needs to be diagnosed and treated, if the child is to have a successful school outcome. Indeed, untreated children with autism who have also ADHD may be unmanageable in

**3**

**Author details**

Michael Francis Fitzgerald

provided the original work is properly cited.

*Introductory Chapter: Autism Spectrum Disorder - Advances at the End of the Second Decade…*

the classroom. They are then excluded, which unfortunately is a very common outcome. There are excellent behavioural strategies for dealing with ADHD, and

relationship between diet and clinical improvement in patients with autism.

Department of Clinical Psychiatry, Trinity College Dublin, Ireland

\*Address all correspondence to: profmichaelfitzgerald@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

They were drawn to this by previous hypothesis about the opioid excess theory of autism and clinical experience by some of the authors. They observed improvements in autistic behaviour in children on gluten- and casein-free diets. These treatments have been around for over 30 years, have always been controversial, but are now becoming far more central to the treatment and understanding of autism or at least autism subgroups. These theories have not gone away because there was always a kernel of truth in them. I myself have observed a subgroup of patients with autism who have benefitted significantly from gluten- and casein-free diets. Other patients in my experience got no benefit from the diets. The reason is that there is such massive heterogeneity in autism, both at the etiological, clinical presentation and response to treatment level. Someday, we may have biomarkers which will allow us to subtype autism spectrum disorders in a meaningful way. There is no available at this time, but this chapter is working on the possibility of a biomarker. This lack of biomarkers is a central problem in all psychiatry, and we have no biomarkers that can be used clinically in psychiatry, as of now. The scientific study by Ann-Mari Knivsberg and colleagues in 1995 [5] is of critical importance for understanding the

*DOI: http://dx.doi.org/10.5772/intechopen.88282*

medications like Ritalin are sometimes necessary as well.

*Introductory Chapter: Autism Spectrum Disorder - Advances at the End of the Second Decade… DOI: http://dx.doi.org/10.5772/intechopen.88282*

the classroom. They are then excluded, which unfortunately is a very common outcome. There are excellent behavioural strategies for dealing with ADHD, and medications like Ritalin are sometimes necessary as well.

They were drawn to this by previous hypothesis about the opioid excess theory of autism and clinical experience by some of the authors. They observed improvements in autistic behaviour in children on gluten- and casein-free diets. These treatments have been around for over 30 years, have always been controversial, but are now becoming far more central to the treatment and understanding of autism or at least autism subgroups. These theories have not gone away because there was always a kernel of truth in them. I myself have observed a subgroup of patients with autism who have benefitted significantly from gluten- and casein-free diets. Other patients in my experience got no benefit from the diets. The reason is that there is such massive heterogeneity in autism, both at the etiological, clinical presentation and response to treatment level. Someday, we may have biomarkers which will allow us to subtype autism spectrum disorders in a meaningful way. There is no available at this time, but this chapter is working on the possibility of a biomarker. This lack of biomarkers is a central problem in all psychiatry, and we have no biomarkers that can be used clinically in psychiatry, as of now. The scientific study by Ann-Mari Knivsberg and colleagues in 1995 [5] is of critical importance for understanding the relationship between diet and clinical improvement in patients with autism.

## **Author details**

Michael Francis Fitzgerald Department of Clinical Psychiatry, Trinity College Dublin, Ireland

\*Address all correspondence to: profmichaelfitzgerald@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Autism Spectrum Disorders - Advances at the End of the Second Decade of the 21st Century*

the autism diagnostic interview/autism diagnostic observation scale (ADI-ADOS), while the rate for current diagnosis which would be the autism spectrum disorder gave a rate of about 116 per 10,000. This means ADI-ADOS is missing over threequarters of patients who would now be described as having an autism spectrum disorder. It is commonly missed by professionals that the diagnosis of autism is a clinical diagnosis by an expert in the diagnosis of autism [4]. Missing autism spectrum disorder has catastrophic effects on the child themselves, the family and

Clearly, only those with higher IQ, the standard IQ necessary for university, will move on to a university. One of the most damaging aspects of the school life, which is almost pervasive and long lasting, is bullying. This leads to anxiety, PTSD, and

It is critical that the quality of training that teachers and classroom assistants have is good. It is almost impossible for those in the classroom to work with children with autism without the clinical autism gestalt. Staff who have this correct sense of the world as seen by a child with autism do extremely good work, become fascinated with the topic and spend the rest of their professional life working with children with autism. Many of the children with autism are the most interesting children a teacher can have the privilege to work with. Many have special talents, and there is a need to build on these special talents and use them in the context of social interaction and building social skills. This will increase the chances of the child living independently and having occupational success later, sometimes which is something that is extremely challenging for persons on the autism spectrum, including those with a high IQ on the autism spectrum. The issues of parent and school relations are very challenging. Because of the nature of autism, both sides can have extreme difficulty seeing things from the others' point of view. Parent/ staff meetings will have to be twice as long, when the child has autism because of the difficulties of communication. It is not surprising that staff can feel persecuted and misunderstood because they are speaking on a different level to the parents. The child with autism requires special understanding on the part of the school to understand their difficulties. It is not surprising because of these difficulties that there are often threats of litigation or actual litigation, because of these interper-

Of course, it is very easy in these situations for both sides to feel misunderstood. It is sometimes helpful for an outside professional child psychiatrist/child psychologist to be engaged to deal with these difficulties. Children with autism and their autistic friends live in a culture in an autistic culture, and it is necessary for teachers to understand them. Teachers have to be aware of the family's and particularly the child with autism difficulty understanding emotions. It is not rare for more than one member of a family to have autism because it has such a high genetic loading. It is critical that teachers make reference to special autism services when the child is depressed, is very anxious or is making threats of killing themselves, which are far from uncommon. The relationship between the teacher and the outside autism professional will be critical to the child's success in school. Severe depression of psychotic proportions may need to be treated with antidepressants, and attention deficit hyperactivity disorder, which is so often co-morbid with autism, is often missed by child psychologists and child psychiatrists, and this needs to be diagnosed and treated, if the child is to have a successful school outcome. Indeed, untreated children with autism who have also ADHD may be unmanageable in

depression in these children, as well as suicidal behaviour.

**2**

school.

**3. Intervention**

sonal communicational problems.

Nodding Syndrome and Autism

Nodding syndrome (NS) is a devastating childhood neurological disorder seen in clusters in Eastern Africa but of uncertain nosology. It is characterized by repetitive head nodding, atonic seizures, cognitive decline, and school dropout, wasting and stunted growth and it occurs in children subject to internal displacement, food insecurity, and exposure to infectious diseases, contaminated environment and with a number of repetitive behavioral abnormalities. On the other hand autism spectrum disorders (ASD) is a group of behaviorally defined neurodevelopmental disorders with lifelong consequences. They are defined by impairments in communication and social interaction along with restrictive and repetitive behaviors. It is a complex disorder associated with a wide range of disparate and seemingly unrelated factors such as; maternal exposure to various chemical substances, maternal exposure to child abuse, maternal evidence of Diabetes, autoimmune diseases, age of either parents at conception, exposure of infants to various chemical substances, low vitamin D levels of the infant at birth, gender of the infant and a large number of genetic factors. There are a number of similarities in the clinical, biochemical and

Spectrum Disorder

behavioral findings in children with NS and ASD.

Keywords: nodding syndrome, autism spectrum disorder, Gulu, Uganda

Nodding syndrome (NS) is a devastating childhood neurological disorder of uncertain nosology [1]. The syndrome is characterized by atonic seizures, head nodding, cognitive decline, muscle weakness, school dropout, thermal dysfunction, internal displacement, food insecurity, wasting, stunted growth, exposures to infectious diseases, contaminated environment and with a number of repetitive behavioral abnormalities [1, 2]. It occurs in clusters in three Eastern African countries (Uganda, Tanzania and South Sudan) and has spatial temporality and clustered in time (during IDP period), space (clustered on either sides of the two main rivers of Aswa and Pager) and person (mainly at 5–15 years of age at onset) particularly in Northern Uganda [3]. The syndrome was first described in 1st scientific meeting organized by the Ugandan Ministry of Health (MOH) and World Health Organization (WHO) in Sheraton, Kampala, Uganda in 2012 [4]. The outcome of the meeting was the agreed WHO epidemiological and surveillance case definition of probable nodding syndrome [5, 6]. It states, "Probable NS cases

and Suzanne Gazda

Abstract

1. Introduction

should meet the following criteria:

5

David Lagoro Kitara, Denis Anywar Arony
