The disease is essentially nonprogressive although some patients, as they grow older, begin to manifest additional visuoperceptive or auditory defects. In the typical case, the outcome is bleak, although many less affected children show improvement in social relationships and schoolwork when given a serotonin reuptake inhibitor, sometimes in very small doses (DeLong; Filipek, personal communication). Administration of the peptide secretin had produced a number of anecdotal successes, but this could not be reproduced in controlled studies. Selective serotonin reuptake inhibitors (e.g., fluoxetine, citalopram) have also shown some benefit in managing repetitive behaviors and mood swings such that medications in this class are being widely prescribed to autistic children. In addition, serious behavioral changes such as self-injurious activities, aggression, and severe tantrums have been treated with drugs such as risperidone. These represent a therapeutic advance but, as pointed out by Hollander and colleagues in their review of the drug treatment of autism, the patients studied were selected for the severity and type of their symptoms for which reason these medications cannot be expected to be of help to all autistic individuals.
Management of Developmental Delay
Because there is little or no possibility of treating most of the diseases underlying developmental delay and there is no way of restoring function to a nervous system that is developmentally subnormal, the objective is to assist in planning for the patient’s care, training, education, and social adjustment. The parents must be guided in forming realistic attitudes and expectations. Psychiatric and social counseling may help the family to maintain gentle but firm support of the patient so that he can acquire, to the fullest extent possible, good work habits and a congenial personality.
Most individuals with an IQ above 60 and no other handicaps can be trained to live an independent life; special schooling may enable them to learn skills useful in a vocation. Social factors that contribute to underachievement must be sought and eliminated if possible.
If the IQ is below 20, institutionalization is almost inevitable, for few families can provide the long-term custodial care that is needed. Often institutional care is necessary for individuals with IQs of 20 to 50. Patients in this group, if stable in temperament and relatively well adjusted to society, can work under supervision, but they rarely become vocationally independent. For the more severely impaired, special training in perhaps hygiene and self-care is the most that can be expected.
Great care must be exercised in recommending institutionalization. Whereas the need will be all too apparent in the gravely impaired by the first or second year of life, the less-severely affected are difficult to evaluate at an early age. As stated earlier, psychologic tests alone are not altogether trustworthy. It is best to observe the patient over a period of time. As noted in Chap. 27, the method of evaluation suggested long ago by Fernald has a ring of soundness, albeit in quite dated terms. It should include observations of (1) the physical, medical, and neurologic findings; (2) family background; (3) developmental history; (4) school progress; (5) performance in schoolwork; (6) practical knowledge; (7) social behavior; (8) industrial efficiency (the ability to participate in work); (9) behavioral disinhibition, which was called in Fernald’s time “moral behavior”; and (10) intelligence as measured by psychologic tests.
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