We concur that autism is a "spectrum disorder," but as the title of our article clearly denotes, our review was not about the entire spectrum. Rather, it was directed toward the child with autism (also known as "autistic disorder" and "classic autism"), the most severe of the three most common pervasive developmental disorders (PDD). We emphasized this group of patients with forethought, because this is the most vulnerable group of individuals, given their complex set of medications and associated adverse orofacial side effects and possible interactions with dental medications.
We concur that children with less severe forms of the disorder may not require ambulatory intravenous sedation or admission to a hospital for general anesthesia. We are not, however, comfortable in construing that children with autism find the physical restraints afforded by the "papoose board" "as a comforter." Please also note that it was we who first noted that the use of "hand-over-mouth" was, at best, controversial.
Over 90 percent of the etiology of autism is derived from genetic factors, and recent research findings indicate that some parents share specific behavioral and cognitive characteristics with their children. Specifically, some of these parents may display mild forms of autistic symptomatology, which collectively is known as "the broader autism phenotype."1–3
In fact, Kanner,4 who first described the disorder in 1943, noted that a number of parents of children with autism were perfectionistic individuals, with an intense interest in abstract ideas, who appeared to lack a genuine interest in developing relationships with others. Contemporaneous studies of the personality traits of the parents of autistic individuals demonstrate that some of them are often aloof, rigid, untactful, hypersensitive to criticism, anxious, withdrawn and difficult and have social problems (for example, few friends).5–7 Pragmatic language problems—manifested as an inability to hold a socially appropriate, fluid and reciprocal conversation with coherence, topic maintenance, adequate eye contact, facial expressions and prosody (rhythm, stress and frequency of speech)—also may be encountered.8
Like their offspring, some of these parents manifest impaired "executive function," an umbrella term used to encompass the processes that underlie goal-directed behavior, such as planning, working memory, inhibition of prepotent responses and cognitive flexibility.9 There is also evidence that some of these parents also may exhibit schizoid personality traits, have "obsessive/compulsive" traits or disorder have an anxiety disorder and be at an increased risk of developing affective disorders, particularly depression.10–13 Thus, dentists and the members of their staffs must be aware that some of these parents may have social, language and behavioral abnormalities, as well as deficits in problem-solving skills that can impede the collaborative treatment process.
We, too, have read all of Courchesne’s original articles relative to head size (which he equates with brain growth) and, in fact, cited one of his articles14 where appropriate. Furthermore, we concur that the preponderance of evidence demonstrates excessive brain growth during components of the pre-natal period as well as during the first two years of life and so stated in our article.
Lastly, we do not deny that autism-like behaviors have been noted in other disorders. However, cause and effect is a very different issue. In fact, Zafeiriou and colleagues15 identified 30 genetic syndromes, many of which have well-defined but diverse causes, that have been described in children with PDDs. The search for the cause of autism is ongoing, because no defining set of pathophysiological mechanisms has been unambiguously elucidated.16
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