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Examples of Symptom Presentation in Blind/Autistic Children in Contrast to Blind/Non-Autistic Children a la DSM-IV Criteria*

Terese Pawletko, Ph.D. & Lorraine Rocissano, Ph.D.

July, 2000

NOTE: Autism is a syndrome comprised of a cluster of behaviors that must be present by the age of 3. Keep in mind, however, that children with autism will not remain static over time but will improve in many of these areas. They are still autistic. This illustrates the importance of doing good developmental histories. Educational classification may vary slightly by state; however, diagnostic criteria used by professionals outside of education rely on DSM or ICD systems. For purposes of this discussion we are referring to the totally blind child. Historically, many of the behaviors exhibited by blind children were labeled as "autistic-like" but were attributed to their blindness. We seek to clarify some of these misconceptions.

1. Qualitative impairment in social interaction, as manifested by at least two of the following:
   1. marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
      
      Behaviors involving vision are not applicable when considering blind children, however, it is possible that blind children may indicate social interest through shifting body posture
   2. failure to develop peer relationships appropriate to developmental level
      • Blind/Non-Autistic
        • Relationships may be delayed but will develop.
        • Shows social curiosity (e.g., ask who is in the room, why a particular person isn't there).
        • Indicate that they enjoy social interaction as noted when they smile in response to hearing a friend is coming over.
      • BLIND/AUTISTIC
        • Peer relationships are non-existent or distorted (e.g., child may pull someone's hair in order to see him cry - like cause/effect toy).
        • Show little social curiosity or interest and in extreme cases may find social interaction aversive.
   3. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)
      • Blind/Non-Autistic
        • Will seek to share information and experiences (even children with moderate to severe MR).
      • BLIND/AUTISTIC
        • No real social interest, no interest in sharing. Exception is high functioning child. Can share, but only on his/her preferred topic, and when older.
          
          * The criteria from the DSM-IV are provided to give professionals a consistent basis for determining diagnosis. However, these criteria alone are not sufficient for diagnosis. The practitioner uses a broad range of information and clinical experience to determine the presence of an autistic spectrum disorder. Likewise, autism checklists have limited usefulness and should not be the basis for diagnosing autistic spectrum disorder.
   4. lack of social or emotional reciprocity
      • Blind/Non-Autistic
        • Can demonstrate empathy toward others (e.g., feel badly if hurts someone).
        • Can engage in socially appropriate give and take.
      • BLIND-AUTISTIC
        • Seems to treat others as object.
        • Does not seem to understand social given and take.
2. Qualitative impairments in communication as manifested by at least one of the following:
   1. delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
      • Blind/Non-Autistic
        • Will develop language. If MR may be delayed but will make efforts to communicate and exhibit pleasure in social exchanges.
      • BLIND-AUTISTIC
        • Language may not develop at all.
        • If there is language it is usually echolalic.
        • Shows no interest in communicating.
   2. in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
      • Blind/Non-Autistic
        • Conversational skills develop within normal range.
      • BLIND/AUTISTIC
        • Little or no conversational reciprocity.
        • If higher functioning, may converse but primarily on a topic of perseverative interest (e.g., commodes)
   3. stereotyped and repetitive use of language or idiosyncratic language
      • Blind/Non-Autistic
        • May have pronomial reversals (like some sighted children),but brief in duration. Otherwise, language develops in ways similar to that of sighted children (Landau, 1997).
      • BLIND/AUTISTIC
        • Extended period of pronomial reversal.
        • Echolalia
        • Pragmatic inappropriateness - may respond with something irrelevant to what was just said; says wrong thing at wrong time.
   4. lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
      • Blind/Non-Autistic
        • Imitative play and make-believe play are compromised at early ages due to lack of vision. However, as children gets older, they do begin to engage in role play with others.
        • Play with objects is appropriate (e.g., rolls and creates engine noises for truck, cuddles doll).
      • Blind/Autistic
        • Generally do not play appropriately with materials (e.g., may spin truck wheels, twirl string; engages in more repetitive actions instead of purposeful actions on objects).
3. Restricted repetitive and stereotyped patterns of behavior, interests and activities, as manifested by at least one of the following:
   1. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
      • Blind/Non-Autistic
        • Blind child's interests can be expected to be restricted compared to the sighted child due to lack of vision.
        • However, the blind child can, relatively easily, be engaged in a variety of activities by an interested adult. 
      • Blind/Autistic
        • Highly restricted interests; may be willing to engage in only one or two activities (e.g, a specific "Price is Right" episode, spinning wheels on truck, flicking giant Lego block repetitively).
        • Very difficult for interested adult to engage child in different activities.
        • Interruption of favorite activity is often met with extreme resistance.
   2. apparently inflexible adherence to specific, nonfunctional routines or rituals
      • Blind/Non-Autistic
        • Shows normal flexibility in normal life events.
      • Blind/Autistic
        • Rigid performance of routines that don't have a function is common.
        • Inflexibility is most evident during transitions or when a routine is changed.
   3. stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements) 
      • Blind/Non-Autistic
        • May rock or eye-poke, but this can usually be redirected. 
        • Child can develop control over these as he gets older.
        • Handflapping, spinning not commonly seen.
      • Blind/Autistic
        • May exhibit a number of motor behaviors - e.g., head roll, hand flapping; rocking one foot to another, etc. These behaviors are very resistant to interruption.
   4. persistent preoccupation with parts of objects
      • Blind/Non-Autistic
        • Preoccupation with parts of objects not characteristic of blind children.
        • Objects, with appropriate instructions are typically used functionally.
      • Blind/Autistic
        • Insist on fiddling with one part of an object or one type of object.
        • Very resistant to interruption or redirection.

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