Aim

To screen for the symptoms of autism spectrum disorder using Indian Scale for Assessment of
Autism.

Basic Concept

Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a neurological and developmental disorder that

affects how people interact with others, communicate, learn, and behave. Although autism can be
diagnosed at any age, it is described as a “developmental disorder” because symptoms generally
appear in the first 2 years of life.

DSM Criteria

A. Persistent deficits in social communication and social interaction across multiple

contexts, as manifested by the following, currently or by history:

1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach
and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or
affect; to failure to initiate or respond to social interactions.

2. Deficits in nonverbal communicative behaviours used for social interaction, ranging, for
example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye
contact and body language or deficits in understanding and use of gestures; to a total lack of
facial expressions and nonverbal communication.

3. Deficits in developing, maintaining, and understanding relationships, ranging, for example,

from difficulties adjusting behaviour to suit various social contexts; to difficulties in sharing
imaginative play or in making friends; to absence of interest in peers.

B. Restricted, repetitive patterns of behaviour, interests, or activities, as manifested by at least

two of the following, currently or by history:

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor
stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or
nonverbal behaviour (e.g., extreme distress at small changes, difficulties with transitions, rigid
thinking patterns, greeting rituals, need to take same route or eat same food every day).

3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong
attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative
interests).

4. Hyper or hypo-reactivity to sensory input or unusual interest in sensory aspects of the

environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds
or textures, excessive smelling or touching of objects, visual fascination with lights or
movement).

C. Symptoms must be present in the early developmental period (but may not become fully
manifest until social demands exceed limited capacities, or may be masked by learned strategies
in later life).

D. Symptoms cause clinically significant impairment in social, occupational, or other important

areas of current functioning.

E. These disturbances are not better explained by intellectual disability (intellectual

developmental disorder) or global developmental delay. Intellectual disability and autism
spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder
and intellectual disability, social communication should be below that expected for general
developmental level.

Clinical Picture

Children with autism show varying degrees of impairments and capabilities. A cardinal and
typical sign is that a child seems apart or aloof from others, even in the earliest stages of life
(Hillman & Snyder, 2007).

A Social Deficit. Typically, children with autism do not show any need for affection or
contact with anyone, and they usually do not even seem to know or care who their parents are.
Sigman (1996) has characterized the seeming inability of children with autism to respond to
others as a lack of social understanding—a deficit in the ability to attend to social cues from
others. The child with autism is thought to have a “mind blindness,” an inability to take the
attitude of others or to “see” things as others do.

An Absence of Speech. Children with autism do not effectively learn by imitation. This
dysfunction might explain their characteristic absence or severely limited use of speech. If
speech is present, it is almost never used to communicate except in the most rudimentary
fashion, such as by saying “yes” in answer to a question or by the use of echolalia—the parrot-
like repetition of a few words. Whereas the echoing of parents’ verbal behaviour is found to a
small degree in normal children as they experiment with their ability to produce articulate
speech, persistent echolalia is found in about 75 percent of autistic children (Prizant, 1983).

Self-Stimulation. Self-stimulation is often characteristic of children with autism. It

usually takes the form of such repetitive movements as head banging, spinning, and rocking,
which may continue by the hour. Other bizarre repetitive behaviours are typical. These children
often show an active aversion to auditory stimuli, crying even at the sound of a parent’s voice.
The pattern is not always consistent, however; children with autism may at one moment be
severely agitated or panicked by a very soft sound and at another time be totally oblivious to a
loud noise.

Intellectual Ability. Compared with the performance of other groups of children on

cognitive or intellectual tasks, children with autism often show marked impairment. For
example, children with autism are significantly impaired on memory tasks when compared with
both normal children and children with intellectual disability. They show a particular deficit in
representing mental states—that is, they appear to have deficits in social reasoning but can
manipulate objects.

Maintaining Sameness. Many children with autism become preoccupied with and form
strong attachments to unusual objects such as rocks, light switches, or keys. In some instances,
the object is so large or bizarre that merely carrying it around interferes with other activities.
When their preoccupation with the object is disturbed—for example, by its removal or by
attempts to substitute something in its place—or when anything familiar in the environment is
altered even slightly, these children may have a violent temper tantrum or a crying spell that
continues until the familiar situation is restored.
Epidemiology

The World Health Organization (WHO) estimates the international prevalence of ASD at 0.76%;
however, this only accounts for approximately 16% of the global child population.

ASD is more common in males but in a recent meta-analysis (Loomes, R. et.al., 2017)
true male-to-female ratio is closer to 3:1 than the previously reported 4:1, though this study was
not done using the DSM-5 criteria. This study also suggested that girls who meet criteria for
ASD are at higher risk of not receiving a clinical diagnosis. The female autism phenotype may
play a role in girls being misdiagnosed, diagnosed later, or overlooked. Not only are females less
likely to present with overt symptoms, they are more likely to mask their social deficits through a
process called “camouflaging”, further hindering a timely diagnosis.

Aetiology

ASD is a neurodevelopmental disorder influenced by a complex interplay of genetic and

environmental factors. Despite extensive research, potential etiological mechanisms of ASD
remain unknown. Although research confirms that genetics plays an important role in the
aetiology of ASD, genetic risk, responsible for up to 60% of cases, is known to be modulated by
prenatal, perinatal, and postnatal environmental factors. (Ostrowski, J., 2024)

Disturbances in Central Nervous System. Certain brain regions including the limbic
system, particularly the hippocampus, amygdala and cerebellum, have been implicated in the
pathophysiologic mechanisms and clinical expressions of the disorder. Evidence from
neuroimaging and postmortem studies has revealed structural abnormalities in those regions of
the brain. Hypothetically, the core abnormalities in the pathogenesis of autism are located in the
amygdala, adjacent limbic structures and corpus callosum. (Shuid, A.N., 2020)

Genetic Contributions.

Sibling Concordance. The researchers also found that a child with multiple autistic
siblings has a higher chance of autism (37%) than a child with only one sibling on the spectrum
(21%). The sex of the infant was also associated with the likelihood of familial recurrence. If the
later-born infant was a boy, they were almost twice as likely as a girl to be diagnosed themselves.
 Twin Concordance. The concordance rate for autism spectrum disorder (ASD) in
siblings is higher for monozygotic (MZ) twins than dizygotic (DZ) twins:

Monozygotic twins. The concordance rate for ASD in MZ twins is between 60–90%.

Dizygotic twins. The concordance rate for ASD in DZ twins is between 3–31%.

Environmental Factors. An environmental risk factor is anything that alters the

likelihood of having a condition and isn’t encoded in an individual’s DNA.

Pollutants. Systematic review and meta-analysis of cohort studies evaluated the

association between exposure to environmental pollutants and ASD. The exposure of pollutants
such as nitrogen dioxide, copper, mono-3-carboxy propyl phthalate, monobutyl phthalate, and
PCB 138, particularly during gestation and postnatal periods, pose health risks and are associated
with ASD. (Cartagena, T.D., et.al., 2024)

Preservatives. Preservatives also act as a causal factor in the development of autism in

the child. A study found that high levels of propionic acid (PPA), a common food preservative,
can cause autistic-like behaviours in rats. PPA can occur naturally in the gut, but eating packaged
foods that contain it can increase the amount of PPA in a mother's gut, which can then pass to the
foetus.

Neurobiological Influences.

Amygdala. Some research suggests that the amygdala may overgrow in infants who go
on to develop autism spectrum disorder (ASD). The faster the amygdala overgrows, the more
severe the ASD symptoms may be. This leads to increased fear and anxiety in the children
because of over secretion of cortisol.

Neuropeptile Oxytocin. Neuropeptile oxytocin is a hormone that helps in socialization

and is known to be a happy hormone. Lower levels of neuropeptile oxytocin are found in
children with autism.

Mercury. Environmental agents, such as mercury, lead, measles, rubella virus, retinoic
acid, maternal thalidomide, valproic acid and alcohol use during gestate on have been evoked to
be implied in the aetiology of autism (London, 2000, Mutter et al., 2005).
 Brain Size. Large head size in the first two years of life is a predictor of the severity of a
child's autism traits at age 4. Large-brained autistic children struggle with everyday skills such as
using cutlery to eat, and their skills tend to decline over the first six years of life.

Pregnancy and Prenatal Complications. Untreated maternal hypothyroidism, use of

certain antiepileptic drugs, use of alcohol, prenatal infections such as rubella, cytomegalovirus,
influenza, etc, uterine bleeding, RH incompatibility, prolonged labour, and hypoxia are some of
the causes which fall under pregnancy and prenatal complications.

Neuro-cognitive Deficits. Difficulty with social interaction, executive dysfunctioning

(planning, inhibitions, working memory), reduced cognitive flexibility, impaired processing
speed, impaired verbal learning and memory, mind blindness are some of the neuro-cognitive
deficits seen in children with autism.

Socio-psychological Factors. Problems with social communication, history of social

problems, internalization, behavioural challenges, suicidal behaviour, repetitive behaviours,
restricted interests are some of the causes that fall under socio-psychological factors.
Description of the Test

The National Institute for Mentally Handicapped (NIMH) developed the Indian Scale for
Assessment of Autism (ISAA) in 2009.

Domains

ISAA consists of 40 items rated on a 5-point scale ranging from 1 (never) to 5 (always).
The 40 items of ISAA are divided under six domains as given below:

Domain I – Social Relationship and Reciprocity. Individual with autism do not interact with
other people. They remain socially unresponsive, aloof and may have difficulty in understanding
another person's feelings, such as pain or sorrow. The have significant problems in use of body
language and nonverbal communication, such as eye contact, facial expressions, and gestures
and establishing friendships with children of the same age.

Domain II – Emotional Responsiveness. Individuals with Autism will have problems in speech
development. They find it difficult to express their needs verbally and nonverbally and may also
have difficulty in understanding the non-verbal language of others. People with autism often,
have echolalia and may repeat a word, phrase or sentence out of context.

Domain III – Speech – Language and Communication. Individuals with autism do not show
the expected feelings in a social situation. Emotional reactions are unrelated to the situation and
may show anxiety or fear which is excessive in nature without apparent reason. They may
engage in self-talk that is inappropriate for their age and may lack fear of danger.

Domain IV – Behaviour Patterns. Individuals with autism may engage in self –stimulatory
behaviour in the form of flapping of hands or using an object for this purpose. They insist on
following routines, sameness and may resist change. Some autistic children may be restless and
exhibit aggressive behaviour.

Domain V – Sensory Aspects. A majority of autistic people are either hyper or hypo sensitive to
light, sound, smell and other external stimulation. They may ignore objects or become obsessed
by them or they may watch those objects very intently or act as if they are not even there. Some
autistic children explore their environment by smelling, touching or tasting objects.
Domain VI – Cognitive Component. Individuals with autism may lack attention and
concentration. They do not respond to instructions promptly or respond after a considerable
delay. On the other hand, individuals with autism may also have special or unusual ability known
as, savant ability in some areas like reading, music, memory and artistic abilities.

Reliability

Internal consistency reliability of ISAA was computed using Cronbach alpha. The alpha
coefficient obtained was 0.93 (p<0.001) for autism group indicating high degree of internal
consistency.

The test-retest reliability of ISAA was also computed. In order to assess the Test-retest
reliability of ISAA, 120 subjects (30% of sample) from autism group were retested after three
months. Correlations ranged from 0.60 to 0.85 in various domains and for the total score it was
0.83 (p<0.001). These results indicate that test-retest reliability of ISAA is good.

Validity

Validity of ISAA test items were determined by correlating the individual item scores with the
total scores, all the items of the scale were significantly correlated with total scores at 0.001
level, except one item (A40), namely 'savant ability' which was significant at 0.5 level.

Norms

ISAA Scores Degree of Autism

<70 Normal
70-106 Mild Autism
107-153 Moderate Autism
>153 Severe Autism
Scoring

Each of the 40 test items is to be rated on 5 categories, out of which one is to be checked. These
are further quantified by providing percentages to indicate the frequency, degree and intensity of
behavioural characteristics that are observed.

Person is completely independent in activities of daily life - Score 2

Person may be able to perform activities of daily life with minimum assistance - Score 3

Person needs assistance in activities of daily life - Score 4

Person is completely dependent on activities of daily life - Score 5

The categories along with the percentages assigned are as follows:

Rarely. (Up to 20%) indicates that the person exhibits this behaviour pattern for up to
20% of the time. This score is normal for their age and socio-educational background - Score 1.

Sometimes. (21 – 40 %) indicates that the person exhibits this behaviour pattern for 21%-40 %
of the time. Some of these behaviours may be a cause for attention and concern, but by and large
they may be considered within normal limits for their age and socio-educational background.

Frequently. (41 – 60%) indicates that the person exhibits this behaviour pattern for 41% - 60%
of the time. These behaviours occur with such frequency and regularity that they interfere with
the persons' functioning in daily life. Behaviour at this level will be definitely disabling.

Mostly. (61– 80 %) indicates that the person exhibits this behaviour pattern for 61% - 80 % of
the time. The given behaviour may occur without any discernible stimulus. The behaviour under
consideration occurs so regularly that it significantly hampers the person in performing daily
activities.

Always. (81% - 100 %) indicates that the person exhibits this behaviour pattern almost all the
time, so much so that it would be considered a major handicap. The behaviour shown is seldom
appropriate to the given situation.

ISAA Scores Percentage (%)

70 40
71-88 50
89-105 60
106-123 70
124-140 80
141-158 90
Above 158 100
Methodology

Precautions

The examiner should have a through familiarity with the test items, test materials, recording and
scoring.

Guidelines for rating ISAA should be adhered. It is advisable to practice test

administration using CD to understand subtle cues and observing examinee behaviour.

Each item of ISAA is to be assessed and a rating is to be given based on the intensity,
duration and frequency of the characteristics.

Conduction

Rapport Formation. The participant was seated comfortably on a chair facing the
examiner. The atmosphere of the testing room was quiet and free from any external disturbance.
The examiner established a rapport by being friendly and appreciative to win over the confidence
of the participant to ensure free reactivity. The examiner had established a rapport with the child
too in order to observe him.

Materials Required. Materials required to conduct ISAA are ISAA assessment sheet,
pen/pencil, and ISAA manual.

Instructions. The ISAA assessment was given to the child’s parent and they were
asked to rate each item from 1-5, where 1 being normal for their age and 5 being completely
dependent on others, on the basis of their observation towards the child. The parent was made
sure that the information provided by them will be completely confidential and would be used
only for practical purpose.

Conduction. The ISAA assessment was given to the child’s parent and were told that
there are a total of 40 items and were asked to rate each item from 1-5, where 1 being normal for
their age and 5 being completely dependent on others, on the basis of their observation towards
the child. Alongside, the child was given few toys and was accordingly observed. Any doubts
that the parent had were cleared properly.

Introspective Report
Initially when I was called by the examiner and was told about the practical, I was a little bit
nervous as I didn’t know what and how to do. But the examiner made sure to make me
comfortable and formed a proper rapport before the conduction. This encouraged me to provide
correct responses rather than showing social desirability. I faced no difficulty while performing
the test.

Behavioural Report

Initially when the parent was called, they were a little nervous because they were fidgeting, their
hands were shaking and they had even asked that will the test be difficult and will the scores be
disclosed. So, in order to calm down their stress, the parent was made comfortable and a rapport
was formed with the parent first and then the instructions were provided related to the
assessment.
Scoring and Interpretation

Domains Minimum Score Maximum Score Obtained Score

Social Relationship 9 45 39
and Reciprocity
Emotional 5 25 11
Responsiveness
Speech-Language and 9 45 30
Communication
Behaviour Patterns 7 35 17
Sensory Aspects 6 30 16
Cognitive Component 4 20 12

Overall, the participant got a total score of 125 which indicates that he has moderate autism of
80%.

Discussion and Conclusion

The aim of our current practical was to screen for the symptoms of autism spectrum disorder
using Indian Scale for Assessment of Autism. ISAA was developed by National Institute for the
Mentally Handicapped in the year 2009.