CMScript 4 of 2025: Focus Autism on Spectrum Disorder

The World Health Organization (WHO) estimates that about 1 in out of every 100 people worldwide has Autism. In South Africa, an estimated 270 000 individuals are living with Autism, with about 5 000 new cases diagnosed annually. Yet, awareness remains low, stigma persists, and many communities lack access to timely diagnosis and support.

While autism itself is not a Prescribed Minimum Benefit (PMB) condition, this edition of CMScript helps members understand the importance of early intervention and access to autism-related care, as some related conditions like epilepsy or depression may be covered under PMBs.

What is Autism Spectrum Disorder?

ASD is a complex condition that affects how the brain develops and functions. It is characterised by challenges in communication, social interaction, and repetitive behaviours or fixed interests. Autism typically appears in early childhood and impacts daily life in different ways. It can affect anyone, no matter their background, race, or income level.

Signs and symptoms of Autism

People with autism are all different, but some common signs and symptoms may include:

• Social interaction and communication: May struggle to make eye contact, read social cues, engage in back-and-forth conversation, or understand the feelings of others.
• Repetitive behaviours: Prefers doing things the same way each time and may get distressed when routines are disrupted. Performing activities that could cause self-harm, such as biting or head-banging.
• Sensory sensitivities: May be overly sensitive or under-sensitive to sensory input such as loud sounds, bright lights, certain textures, or even touch, often leading to discomfort or distress.
• Unusual speech patterns: Might speak in a monotone, robotic, or singsong voice. May repeat phrases or struggle with tone and rhythm in speech.

Women may display autism differently, as they are more likely to have learned to hide signs to ‘fit in’ by copying people who do not have autism, which can delay diagnosis.

Diagnosis and treatment

There is no single medical test for autism, but diagnosis may involve:

• Developmental checklists and interviews with parents or caregivers.
• Evaluations by specialists such as paediatricians, psychologists, or speech therapists.
• Diagnostic criteria for ASD according to DSM-5 (Diagnostic and Statistical Manual, Fifth Edition).

While there is no cure for autism, early diagnosis and highly structured and specialised programs can greatly improve outcomes. Effective support includes:

• Therapy: Speech, occupational, and behavioural therapy to support communication, motor skills, and behaviour.
• Family Support: Parent training and counselling to help caregivers manage challenges and support development.
• Education: Individualised Education Plans (IEPs), special needs support, or inclusive classroom placement.
• Social & Life Skills: Training to improve daily living, social interaction, and workplace readiness.
• Medication: Used to manage symptoms like anxiety, aggression, or mood disorders when needed.

Prescribed Minimum Benefit (PMB) regulations

Autism Spectrum Disorder (ASD) is not listed as a Prescribed Minimum Benefit condition.

This means that:

• Medical schemes are not legally required to cover all costs related to ASD under PMB rules.
• Access to tests, treatment, and care is subject to your specific scheme’s rules. Any limits or sub-limits in your plan will apply.

However, some health problems linked to ASD, like depression, may be covered as PMB conditions on their own. These will be paid for in line with the PMB rules.

It is important to read your medical scheme rules and check which services they will cover for ASD-related care.

Remember to be kind, autism is not a limitation but a different way of experiencing the world. With understanding, support, and acceptance, individuals with autism can lead fulfilling lives and contribute uniquely to society.

Download the full CMScript here.