Autism

**Autism**, also called Autism Spectrum Disorder (ASD) describes a group of complex disorders of brain development such as Asperger’s Syndrome, Atypical Autism and Childhood Autism.
 ASD is a lifelong developmental condition that affects the way an
individual relates to his or her environment and their interaction with
other people. The word “spectrum” describes the range of difficulties
that autistic people may experience and the degree to which they may be
affected. The main areas of difficulty are in social interaction, verbal and nonverbal communication
 and restricted or repetitive behaviors and interests it also includes
affects of motor communication in the child and typically develops at
the age of 2-3 years old.

People who have autism find it difficult to act in a way that other
people think is "normal". They find it difficult to talk to other people
 and to look at other people. Often, they do not like being touched by
other people. A person who has autism seems to be turned inwards. They
may talk only to themselves, rock themselves backwards and forwards, and
 laugh at their own thoughts. They do not like any type of change and
may find it very difficult to learn a new behaviour like using a toilet
or going to school.

Autism is caused by the way that the brain develops, both before and
after a baby is born. Around the world, about one in every 160 children
has an Autism Spectrum Disorder.

## History

### **Early history**

The word “autism” comes from the Greek word “autos”, meaning “self.” The term describes conditions in which a person is removed from social interaction—hence, an “isolated self”. The term "autism" was first used by a psychiatrist named Eugen Bleuler in 1911 to refer to one group of symptoms of schizophrenia. Sigmund Freud adopted the broad concept of Bleuler and equated the term autism with narcissism.

### **Discovery**

Three
 decades later, researchers in the United States began to use the term
autism to describe children with emotional or social problems. Two
researchers by the name of Hans Asperger and Leo Kanner were the pioneers of the research study for autism in the 1940s.
In 1943 Leo Kanner (a doctor from Johns Hopkins University) did a
study of 11 children. The children were very intelligent. But he found
out that they had difficulties like changing environments, being
sensitive to certain stimuli, having speech problems and allergies to food. Later he named the children’s condition “early infantile autism”. Leo Kanner's discovery is now called *autistic disorder*, *childhood autism*, *infantile autism*, or simply *autism*.

In 1944 Hans Asperger studied separately a group of children and
found very similar conditions. But the children in Hans Asperger's group
 did not repeat words. Also, they had no speech problems like Kanner's
did. However, the children did have problems with fine motor skills such
 as holding a pencil. The children he studied seemed to be clumsier than
 other children. They also had “[...] a lack of empathy, little ability to form friendships, one-sided conversation, intense absorption in a special interest and clumsy movements”. Hans Asperger described a "milder" form of autism, his discovery is now called Asperger syndrome.

**The *refrigerator mother* theory**

In
 1943 and 1949, Kanner described the children he studied in scientific
papers. In these papers, he wrote that he thought the children's parents
 were not loving them enough. He wrote that this might be part of the
reason why the children had autism. For example, in 1949 he wrote that the children's parents showed no warmth, or love, to their children. He thought the parents were so "cold" that he compared them to refrigerators:

This idea became known as the *refrigerator mother theory*. For decades parents were blamed for causing their children's autism by not loving their children enough. By now it is known that this theory is invalid.

### **Later history**

Schizophrenia
 and autism were linked in many researchers’ studies. Only since the
1960s, medical professionals began to have a separate understanding of
these two disorders. Since 1980, Kanner’s so called early infantile autism is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Precisely because of the vague distinction between schizophrenia and autism, the DSM came out with a more accurate definition
 of autism in 1987. Henceforth, early infantile autism is called autism
disorder. Furthermore, for the first time the DSM introduced
standardised criteria to diagnose
 autism. The fourth edition of the Diagnostic and Statistical Manual of
Mental Disorders expanded the definition of autism and included milder
cases of autism. But especially the Asperger’s syndrome was added in
1994. With the release of the fifth edition of the DSM in 2013 the
subtypes of autism are summarized into the general term Autism Spectrum
Disorder (ASD). Individuals are now diagnosed on an autism spectrum with
 varying levels of intensity (mild, moderate and severe).

## Symptoms

### **Interaction**

A baby
 without autism will usually be interested in other people. Autistic
babies may like objects more than faces and other people. They may look
for a second at a face, but quickly turn. They may not smile or may just
 smile at what they are interested in. Autistic children
 may usually like to be by themselves. They may not be interested in
making friends. They may also not react normally to hugging and other
signs of love
 by their parents. This does not mean that they do not love their
parents, they just do not know how to say it. Often, it is difficult for
 them to know what other people think or feel. For example, they might
not see much difference between whether a parent is smiling or feeling sad.
 They may laugh and cry at the wrong times. Some do not understand that
someone else can have different thoughts and feelings than they do. This
 is a sign of a missing Theory of Mind.

### **Communication**

An
 autistic child might not try to talk, point, or otherwise try to get a
message across by one year of age. Some do not understand language at all. Those who speak usually do not show changes in pitch and tone.
 The voice sounds monotonic. But pitch and tone are important for
communication. It helps to interpret the meaning of the words. Often,
the use of homographs is difficult for people diagnosed with autism. Many autistic people have problems to understand gestures
 or facial expression. They seem to have only a limited amount of facial
 expressions. This makes it difficult to express themselves or
understand the expressions of others. However, they may try to
communicate using pictures in books, photos, signing or picture cards
when they do not speak but have clear understanding of language.

### **Restricted behaviour**

Some
 autistic people spend a lot of time doing the same thing over and over
again like spinning in circles or putting things in order. Other typical
 behaviours are rocking, twisting and flapping. These behaviours do not
serve as communication. They often last up to adulthood and may turn
into obsessions or motor tics.
 Some autistic people may also be interested in unusual things, and may
spend all of their time learning about their interests. Many autistic
people do not want any change. They will do exactly the same things
every day and may even get upset if anything changes. But some can
tolerate a change in routine with forwarning.

### **Sensitivity**

When comparing autistic and non-autistic children, the autistic children show a greater sensitivity in all senses.
 This sensitivity may increase over age. But possibly autistic people
are only better able to express sensory disturbances with age.
Many autistic children like junk food
 such as chips, crisps and lemonade but avoid vegetables. Often they do
not like soft, mushy or lumpy food. Many do not want to try new foods.
Many autistic children also try to eat metal, plastic, paper and stones.
 Sometimes autistic children do not seem to notice strong smells like
foul scents. Numerous autistic children do not like to touch wet or
sticky substances.
 Often they do not like to be touched by other people. The response is a
 distressed reaction like crying. Many autistic children do not show any
 sign of pain after a bee sting, a burn or a hard fall.

When it comes to sound, autistic children are attracted to specific sounds from aeroplanes,
 the ticking of clocks and other mechanical sounds. Often autistic
children notice sounds earlier than others do. But many appear to be deaf
 when it comes to the human voice. Background noises like music,
conversations or the wind can be very distracting for them. Many
autistic children make unusual sounds that seem to be comforting for
them. It is often noticed that their loudness of speech is too soft, too
 loud or changing continuously between these two levels. This may show a
 changing comfortable listening level.

A lot of autistic children pay attention to detail. They can look at
pictures or books for a very long time. Some are frequently found to
gaze into space.

A few autistic children show very good balance skills. Some do not show any dizziness after spinning around for a long time.

## Frequency

Different studies resulted in different numbers of the frequency
 of autism spectrum disorders. One study stated ten cases of classical
autism, 2.5 cases of Asperger's syndrome and 15 cases of mild autism (PDD-NOS) in 10,000 people - tendency: increasing. Other sources speak about 60 autism spectrum disorder cases in 10,000 people.
 However, the number of autism cases is not equal in men and in women.
Here, the results of studies vary highly. Researchers in general say
that 3-4 men are diagnosed for every woman that is diagnosed. This ratio decreases for severe cases to 1:1. It increases for high-functioning cases and in Asperger's syndrome reaches a ratio of 8:1. Recently, the awareness has increased that this ratio may be so high because studies are simply missing female autistic people.[19] This could be because tests for autism typically focus on male autism traits.
 Another possible explanation is that autistic females may be better at
adapting to social expectations and hiding their social problems. Studies
 have suggested that the brains of autistic females may rather be like
neurotypical men’s (non-autistic men) brains of the same age.
 These could be reasons why it is not so easy to realise whether a woman
 is autistic - and therefore, why more men than women are diagnosed.

## Types of Autism Spectrum Disorders

Over
 the past years, individuals have been using the terms "autism" and
"autism spectrum disorder" like they mean the same thing. Autism is a
spectrum disorder. This means that some people who have autism are only
mildly affected. These people may go to regular schools, go to work, and
 have partners and families. Some people are affected worse than others.
 These people may be able to take care of most of their own needs at
home like dressing and getting food, but not be able to have a regular
job or travel alone. A person who has severe autism may need to be cared
 for all their life. Few people with autism are extraordinarily gifted or talented. These people are said to have savant syndrome. They are often very good at just one thing in particular, like mathematics, playing the piano or remembering football scores.
The overall category of the Autism Spectrum Disorder is called Pervasive Developmental Disorder.
 The name describes medical conditions with developmental problems in a
number of fields. In most cases, when referring to the Autism Spectrum
Disorder, we are referring to the most common disorders:

The different categories, the so called “International Classification of Diseases” (ICD), are defined by the World Health Organization.
 As shown in the table, the diseases vary in several points. These are
the age of onset, social interaction, communication and behaviour. An
individual belongs to a certain category, depending on the areas of impairment.
 All three may seem similar in symptoms, yet are not the same. Still,
people within one group show similar symptoms. The groups can be used to
 search for an underlying cause of the disease and to provide a better
treatment.

## Causes

Scientists do not know exactly what causes autism. There may be many different causes for the different types of Autism Spectrum Disorder. Scientists do know about some things that make a person more likely to have an Autism Spectrum Disorder.

### **Genetics and Heritability**

The autism spectrum disorders are highly heritable disorders.
 This means that it is very likely (over 90%) that the child of an
autistic person will also be on the autism spectrum. The reason for this
 are certain genes.
 These genes are linked to autism and are passed on from a parent to the
 child. Already Leo Kanner and Hans Asperger noticed that fathers of
autistic children often preferred being on their own over being with
people. Therefore, Kanner and Asperger suspected a genetic cause.
Studies with families with a child on the autism spectrum were done to
investigate this theory.
 They found that sometimes the children’s parents (fathers as well as
mothers) also show social difficulties, shyness and problems with
understanding contextual
 information when talking to someone. Some studies have found this in
only 10 out of 100 families, some in as much as 45 out of every 100
families.
Moreover, twin studies showed that it is much more likely that identical twins
 are both on the autism spectrum than that non-identical twins are both
on the autism spectrum. Identical twins have nearly the same DNA.
 Therefore, it is highly probable that they are either both autistic or
both not autistic. Non-identical twins share only half of their genes
which makes it less likely that they both have the disorder. Scientists
have shown that the recurrence risk (the likelihood that a child is on
the autism spectrum if it has a sister or a brother that is autistic as
well) is 20 to 80 times higher than the probability for having the disorder in the average population.

However, it is not a single gene that increases the risk for autism
spectrum disorders. Several genes have been linked to the disorder. All
of the identified genes can in sum only explain one or two out of every
ten autism cases. None of the genes that have been found to play a role
in autism can explain more than one out of every 100 cases.

The genetic influences include:

* mutations,
* genetic syndromes (e.g. Fragile X syndrome),
* de novo (newly occurring in a family) as well as inherited copy

number variations (CNV) - a CNV is the duplication or deletion of a gene
 - and

* single nucleotide variants (SNV) - an SNV is a change in one nucleotide that occurs with very low frequency.

The affected genes influence:

* the interaction between brain cells and synaptic functioning,
* neuronal growth and neuronal migration (the wandering of a neuron from its birthplace to its final location in the brain) and
* inhibitory and excitatory neurotransmission.

### **Neural Correlates**

Researchers have not found a single neuronal correlate for autism spectrum disorders, i.e. no abnormal functioning of the brain
 is the only cause of autism. Nevertheless, scientists found some
differences between the brains of autistic people and the typical human
brain. These differences lie in the anatomy
 of the brain, the activity in certain brain regions as well as in the
connections between brain regions. It is a general tendency that
autistic people use the same brain regions as other people but show
different activity. In some areas the activity is less, in others it is
stronger. However, this may only be true for male autists. Throughout
the last years, studies have shown that brains of autistic women might
be like normal men's brains.
Some researchers grouped autistic people's difficulties into three main areas in order to investigate their neuronal basis.

#### **Theory of Mind**

Researchers
 say that building a Theory of mind is one of the main problems for
autistic people. This makes it difficult for them to interact with
others. Problems in social interaction are probably worsened by low
preference for social stimuli, such as faces. This tendency has been
found in studies tracking the person’s eye movements and in EEG
 studies. EEG studies showed lower than normal activity in the fusiform
face area (FFA), a brain region that is usually active when seeing
faces. However, the results of other studies could not show this.
Also, scientists measured brain activity of people on the autism spectrum with fMRI while they were thinking about their own emotions.
 They found activity in the same brain regions as in non-autistic
people. The difference was that some regions which are important for
thinking about oneself and emotions (especially the anterior insula)
were less active in autistic people.
 Other brain regions were much more active. These findings may explain
the difficulties people with autism experience when trying to understand
 complex facial expressions and emotions (such as shame, jealousy).

#### **Executive Function**

People on the autism spectrum show a lower ability for executive function. Executive function means physical,
 emotional and cognitive self-control. This includes planning actions,
focusing, shifting attention and flexibility of behaviour and thinking.
Autistic people's ability can improve but it will remain below
non-autistic people's ability in executive function.
Problems with executive function are probably caused by large networks in the brain. Grey matter and white matter irregularities have a negative influence on the way different brain regions work together (functional integration). A smaller corpus callosum leads to abnormalities in working memory (an active process of keeping a memory until it is needed)  and planning actions.

#### **Central Coherence**

Central
 coherence is the ability to build wholes out of parts. It is weak in
people with autism. This means that autistic people focus more on
details. They cannot build wholes out of them. Not being able to pay
attention to wholes results in difficulties with perception
 and language. Therefore, people with autism usually need more time for
dealing with information coming from their surroundings. As a
consequence, they typically also need more time for responding. However,
 performance varies between people on the autism spectrum. Moreover, the
 term central coherence may include many interacting aspects. This makes
 it difficult to find the cause for it in the brain. Neural correlates
for central coherence are not yet known.

### **Familial risk factors**

The risk for autism spectrum disorders can be increased if the mother uses thalidomide, valproic acid or drinks too much alcohol during pregnancy. The risk for autism also increases with the age of father and mother at the time of pregnancy.
Scientists know that parents do not cause their children's autism by not being loving enough.

### **Vaccines**

Scientists do know for sure that vaccines do **not** cause autism. Vaccines do not even make a person more likely to have autism - even if
 they are already at a high risk for autism before they get their
vaccines.
In 1997 A. Wakefield and others found autism signs one month after the measles-mumps-rubella (MMR) vaccine was applied. They released a paper in which they claimed that autism is caused by the MMR vaccine. However, the study had several flaws:

1. they did not exclude children of whom a genetic cause was known
2. they did not assess the children's abilities before the vaccine was given
3. neuropsychological and endoscopic assessments were not blind
4. they did not have control subjects.

Also, no plausible biological mechanism could explain how the MMR vaccine leads to autism.
 Since then many case-control studies have been done to investigate the
relationship between vaccines and autism. This means, they compared a
group which was vaccinated with a group that was not vaccinated but
apart from that identical. They did not find MMR vaccines to be the
cause of autism. Neither did they find an increased risk for autism by the vaccination.

Parents also worried that thiomersal (US: thimerosal - a substance
that makes vaccines and other medicines usable for a longer time) might
cause autism because it contains mercury. No harm from the amount of ethylmercury in vaccines was known. Yet, vaccines for infants
 containing mercury were taken from the market. Nevertheless, thiomersal
 as a cause for autism is biologically also not biologically. Mercury poisoning
 triggers clearly different symptoms than autism. Still, researchers did
 studies about this topic. They did not find a connection between
thiomersal and autism.

Finally, a third theory was suggested. It was stated that many vaccines at the same time would weaken the immune system
 of infants. However, autism is not a disorder that is related to the
immune system. Furthermore, single and also many vaccines do not weaken
the immune system.

## Diagnosis

Diagnosing autism is difficult, since there is no medical test like a blood test. Instead, a diagnostic evaluation involves a team of doctors and other health professionals such as pediatricians, psychologists, speech and language pathologists, who are experienced in diagnosing ASD and know the individual.

### **Diagnosis in children**

A
 reliable diagnosis can usually be made by the age of two. At the age of
 18- and 24-month every child should visit a pediatrician and receive
well-child check-ups. If the screening shows abnormalities, an
additional evaluation is needed. In this evaluation a team of
professionals will interview parents or carers about the child’s
behaviour and observe the individual in multiple settings. Behavioural
assessments, physical assessments and laboratory tests such as clinical
observations, developmental and intelligence tests will be done too.
Reviewing a detailed developmental history of the child is also
essential in order to receive a diagnosis.

### **Diagnosis in adults**

Autism
 can also be diagnosed later in life. But it is more difficult because
symptoms of autism may overlap with symptoms of other diseases as for
instance learning disability or obsessive-compulsive disorder.
 Psychologists developed behavioural checklists for the purpose of
diagnosing children. These checklists do not apply for adults since they
 often unconsciously learned to hide their symptoms. An expert, most
likely a psychologist, does not only ask the adult about concerns,
challenges in social interaction and communication
 or behaviour routines and interest. He also tests the adult in
standardised tests. These tests consist of self-assessments in social
interaction, communication and relationships. To make a diagnosis
information about the developmental history is also required.

### **Diagnostic and Statistical Manual (DSM-5)**

In
 2013, the American Psychiatric Association published the fifth edition
of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). In
 order to be diagnosed with autism, a person must fulfill two
standardized criteria. It is important that individuals must show
symptoms from early childhood, even if those symptoms are recognized
later. These symptoms have to limit everyday functioning. Additionally,
these symptoms cannot be explained by an intellectual disability or a developmental delay.
Autism Spectrum Disorder is characterized by difficulties in social
interaction, verbal and nonverbal communication and repetitive
behaviours.

### **Diagnostic Criteria**

==== Long
 lasting deficits in social communication and social interaction in
multiple contexts, as explained by the following - currently or by
history ====

1. Deficits in social-emotional interaction (e.g., responding

inappropriately in conversations; reduced sharing of interests, emotions
 or affect; failure to respond to social interactions)

1. Deficits in nonverbal communicative behaviours used for social

interaction (e.g., difficulties with interpreting both verbal and
nonverbal language like gestures, tone of voice, facial expressions;
abnormalities in eye contact and body language; deficits in
understanding and use of gestures; a total lack of facial expressions
and nonverbal communication)

1. Deficits in developing, maintaining, and understanding relationships (difficulties in making friends, no interests in peers)

==== Restricted,
 repetitive patterns of behaviour, interests, or activities, as
explained by at least two of the following - currently or by history ====

1. Stereotyped or repetitive motor movements, use of objects or speech (e.g., always using the same movements, objects or words)
2. Insistence on sameness, inflexible adherence to routines or

re-occurring patterns of verbal or nonverbal behaviour (e.g., highly
sensitive to changes in their environment; extreme distress at small
changes; inflexible thinking patterns, overly dependent on routines)

1. Highly restricted, fixated interests that are abnormal in intensity

or focus (e.g., intensely focused on inappropriate items or unusual
objects; highly-focused interests)

1. Hyper- or hyporeactivity to sensory input or unusual interest in

sensory aspects of the environment (e.g., experience over- or
under-sensitivity to sounds, touch, tastes, smells, light, colours,
temperatures or pain)

### **Co-occurring conditions**

Autism
 spectrum disorder includes a wide range of symptoms, skills and levels
of disability. Some autistic people also have learning disabilities, mental health issues or other conditions. This means that autism can also co-occur with other diseases and symptoms of the following disorders:

* Attention Deficit Hyperactivity Disorder
* Obsessive-Compulsive Disorder
* Learning Disability
* Intellectual Developmental Disorder
* Anxiety Disorder
* Intellectual Disability

In the DSM-V, a diagnosis of autism excludes making a formal
diagnosis of other psychiatric disorders. Therefore other mental health
conditions may be undiagnosed in an autistic person, because it is
impossible to make a comorbid clinical diagnosis.

## Treatment

Since
 autism is a spectrum, every person with autism is different. Different
treatments help different people. There are a few different categories
of treatment. The main ones are medication, different therapies and diets. The treatment is fitted depending on what a person with autism needs.

### **Medication**

It
 is still unclear what causes autism. There may be a few causes. At the
moment, it is only possible to lower the symptoms of autism. A full
recovery from autism is not possible. If therapies cannot reduce the symptoms of autism, medications are used additionally. Often, several medications are used at the same time to treat different symptoms of autism.

#### **Selective Serotonin Reuptake Inhibitors (SSRI)**

Serotonin is a chemical messenger. It helps to transport signals between cells. It is very important for the development of children, sensory perception,
 movements, learning, memory and sleep. All these functions are impaired
 in children diagnosed with autism. Researchers still try to find a link
 between serotonin and the development of autism. Yet, substances that
inhibit the transport of serotonin have been relatively effective. The selective serotonin reuptake inhibitors (SSRI) stop the cells from taking up serotonin. Therefore more serotonin is available for the transport of signals.[44] In the beginning, SSRIs were used to treat depressions
 in adults. But it also helped people diagnosed with autism. It helps to
 treat repetitive behaviour, aggression, the sudden outburst of bad
tempers, hyperactivity and maladaptive behaviours like hurting themselves. Still, the SSRIs can have many side-effects.
 Usually the medication is better tolerated by adults than by children.
Examples of SSRIs are Clomipramine, Fluvoxamine, Sertraline,
Venlafaxine, Trazodone and Mirtazapine.

#### **Antipsychotic medication**

Dopamine is a chemical messenger in the brain. It helps to fulfill movements, release hormones and strengthen cognitive
 abilities. Researchers found that increasing the amount of dopamine in
the brain will worsen the symptoms of autism. Decreasing the amount of
dopamine will help to reduce symptoms of autism. Substances that help to
 reduce symptoms of autism are the antipsychotic drugs.
 There are two types of antipsychotic medications. One of the types are
typical antipsychotics. They block the sites where dopamine would bind
to a cell. Atypical antipsychotic drugs on the other hand block the
sites where dopamine or serotonin would bind to a cell. Antipsychotic medicine is the most successful treatment for excitability in autism. It can also help to reduce aggression, self-injury, hyperactivity and repetitive behaviour. But it may have many side-effects Originally, antipsychotic medications were used to treat mental disorders like depression, bipolar disorder or schizophrenia. Examples of antipsychotic drugs are Haloperidol, Clozapine, Risperidone and Paliperidone.

#### **Psychostimulants**

In the beginning, psychostimulants
 were only used for patients with Attention Deficit Hyperactivity
Disorder. Researchers found out that they can also help patients with
autism. The medication can reduce hyperactivity and inattention in
people with autism. The medication can have many side-effects. Examples
are Methylphenidate, Clonidine and Guanfacine.

### **Picture Exchange Communication System (PECS)**

The Picture Exchange Communication System (PECS) is designed for autistic people who do not speak. Pictures and symbols
 are used to communicate. For example, an autistic child wants to have a
 cup of water. So, it would show its mother a picture of a cup of water.
 Thereby, the mother knows what the child wants. So to say, the pictures
 and symbols will replace speech.
 The aim is a constant use of these symbols and pictures and to increase
 communication. Usually, this way of communication does not improve the
spoken language.

### **Diet**

People with autism often have problems with their digestive organs like the stomach or gut. These problems could be inflammations, abdominal pain, gas, diarrhea or bacterial overgrowth. The reasons may be malnutrition,
 food intolerances or allergies. Specific food products causing these
problems are excluded from the diet. In many cases, products containing gluten or casein,  the main protein occurring in dairy products, are excluded. In many cases vitamins, minerals as well as essential fatty acids
 are additionally provided. A big problem is that many autistic people
cannot tell that they have pain. Therefore many problems concerning the
digestive organs stay undetected.

### **Therapies**

#### **Occupational Therapy**

Typically,
 autistic people are either far more or far less sensitive to sensory
information. For example a ringing telephone is perceived much louder or
 only very soft. This can make it very difficult to interpret the
sensory information and create a good response to it. Because of that,
autistic people often show enormous difficulties to fulfill daily life
activities. Occupational therapy helps autistic people to minimize these
 difficulties. Individual therapy plans are created. The therapist tries to help the autistic person in many different aspects.
One aspect is the sensory integration.
 Here the therapist helps the autistic person to make sense of the
different sensory inputs. This part of the therapy is important because
sensory information is important for learning, communication and
performing movements. An example to make children more aware of the
sense of touch can be playing with finger paint or collecting objects
from a bag of dried beans. Another important aspect of occupational
therapy is the training of daily life activities. Here, the person
learns things like getting dressed, eating, personal hygiene, cleaning,
shopping or financial management. These activities include several
steps. Usually only one step is trained at a time. Then it gets combined
 with the steps that the person has already learned.

Play therapy is also important - especially for children. It helps to
 learn about emotions like happiness or anxiety. It also helps to learn
certain behaviours. An example would be learning to shake hands with
unknown people instead of hugging them. The play therapy can also help
to solve problems, learn basic forms of communication and improve
creativity.

Free time between therapeutic activities is important as well. Here,
the person can do whatever he or she likes. For example, playing with
toys, sleeping or doing a physical activity like running, swimming or
climbing. Sports can also help to reduce repetitive movements, improve
movement coordination and is a possibility to interacting with other
people.

#### **Therapy with Animals**

Often
 animals are used to help autistic people. Most often dogs or horses are
 used. The people diagnosed with autism can care for these animals, pet
them and in the case of the horse even ride on them. Studies showed that
 the interaction between an autistic person and animals can increase
communication, reduce stress, fear, aggression and reduce the severity
of the symptoms of autism.

#### **Music Therapy**

Music
 therapy consists of two parts: One is an active listening part. Here,
the therapist is making music himself or playing music from a record.
 In the other part, the autistic person can make music himself like
playing an instrument or singing. Music therapy will improve different
aspects of communication.

#### **Art Therapy**

Here,
 different materials and techniques are used to draw pictures. The aim
of this therapy is to make the autistic person more flexible and relaxed
 and to improve communication skills, self-image and learning skills.
The effects of the therapy can be long lasting and transferred to the
school, work or home setting.