Field Work Evaluation.docx

Running head: FIELD WORK EVALUATION

BPY 23023 Abnormal Psychology II

Field work evaluation

Name: Chen Jing Shi (201720033) Sharmila Subbaya (201710009) DATE: 23 November 2018 Lecturer: Ms Nazrila Shaherah

FIELD WORK EVALUATION

1.0 Background information The practicum site that we have visited was Nur Kidz which is a learning centre for children with special needs and a majority of the children attending are diagnosed (either officially or non-officially) to have autism spectrum disorders. The child that we chose to observe is a five-year-old Malay Muslim boy named Azeem. He has been attending the centre for approximately a year and in recent months he has started to attend five days a week. Azeem was never diagnosed officially in a clinic to have autism spectrum disorder (ASD) but before starting his classes at the centre, the centre's therapist had already interviewed and unofficially diagnosed him to be ASD with the hyposensitive sensory system. Hence, accepting his enrolment at the centre. Aside from having ASD, Azeem is a fairly healthy boy with no other known medical conditions. He is not hostile, has a fairly normal temperament, patient, very obedient and is polite. When it comes to the things or activities that he is interested in, he would be very enthusiastic and excited about completed tasks. His favourite objects are toy cars, puzzle games and anything bright and colourful. Prior to attending classes at Nur Kidz, Azeem has never attended any other learning centre or preschools. But after attending Nur Kidz, his parents have also started to bring him to Joyous Kiddy Therapy Centre for speech therapy and Klinik Pakar Kanak-Kanak Adda for occupational therapy. Azeem’s family is considered to be well to do as his father is a business owner and his mother is a housewife. Due to this, his family is also considered to have high social economic status. At home, Azeem is the youngest child and has an elder brother and an elder sister only. His father is a Singaporean while the rest of his family members are Malaysian including Azeem. According to Azeem’s teacher, both of his parents are cooperative, understanding and are also acceptive of his condition. The parents often take turns to fetch Azeem and sometimes

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they both would come together. They also often follow up with the teacher to understand Azeem’s progress in class and at home. From this, we can tell that his parents put in a lot of effort in taking care of him.

2.0 Assessment The assessment of autism spectrum disorder (ASD) in children is important for several reasons.

For these reasons, assessment allows access to proper resources, support and

assistance. More importantly, it facilitates understanding of the child by those who live with them, teach them and interact with them in their everyday lives. It also enables families to plan for a future that may be somewhat different from the one they expected for their child and for themselves. Henceforth, we include several diagnostic assessments or evaluation for Azeem which includes hearing screening, developmental or cognitive assessment, speech and language assessment, motor skills assessment, and sensory sensitivities assessment.

2.1 Hearing screening Hearing

impairments

not

only

impact

learning,

but

they

could

also

affect speech and language development as well as social functioning (The Children's Hospital of Philadelphia, 2016). Significantly, when ASD or a communication problem is suspected, a hearing evaluation is often recommended. For this reason, children with hearing loss may demonstrate symptoms similar to those of ASD, particularly within the communication and socialization areas (The Children's Hospital of Philadelphia, 2016). Likewise, in the case of children with significant hearing loss or deafness, when compared to peers with normal hearing, their speech may differ, and they may rely more heavily on gestures (The Children's Hospital of Philadelphia, 2016). Also, the inability to hear may limit social interaction with peers and 2

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cause the kind of deficits in social skills often seen in children with ASD. Moreover, it is possible for a child to have both ASD and hearing impairment (Alzahrani, 2015). Specifically, the similarities in communication and socialization symptoms between hearing impairment and ASD populations, together with the possibility of dual diagnosis, can present challenges for differential diagnosis (Alzahrani, 2015). Specifically, based on our discussion with the teacher, Azeem has been assessed with no hearing impairment.

2.2 Developmental or cognitive assessment Notably, the reason for the cognitive assessment is to examine the child's behaviour in different situations (Long, Gurka, & Blackman, 2011). The cognitive assessment is crucial as the therapies can learn more about how the child thinks, how the child organizes and plans or solves problems (Long, Gurka, & Blackman, 2011). Sometimes this is done by a brief screening, or it may be a more thorough assessment of developmental or cognitive levels performed with standardized instruments (Long, Gurka, & Blackman, 2011). While screening may specify whether a more thorough assessment is suggested, a comprehensive assessment is needed to determine whether a child has ASD (Long, Gurka, & Blackman, 2011). However, intellectual or cognitive functioning is considered to be very “plastic,” or changeable for children under six years old (Breslau, Chilcoat, Susser, Matte, Liang, & Peterson, 2001). Therefore, screening or testing yields an approximation of developmental level compared to same age peers, but it does not surely predict what future abilities will be (Breslau et al., 2001). After the age of six, IQ is much more stable and it is essential to know where the child’s developmental level or IQ is, compared to other children his age, because this provides fundamental information about what to expect with regard to learning, talking, and interacting with others (Breslau et al., 2001). For instance, developmental and cognitive tests for young

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children can include pictures, puzzles, blocks, drawing, cards, matching items, and other toys and games. Since ASD is a developmental disorder, the teacher should know what Azeem's overall developmental level is before they can determine if social and communication development has not kept up with other domains of development.

2.3 Speech and language assessment An assessment of speech and language functioning is vital for the diagnosis of ASD. The assessment can be a structured testing session, a brief set of screening activities or a clinical observation as a speech-language pathologist (SLP) plays with the child (Mody & Belliveau, 2013). SLPs focus on two basic aspects which are language and speech. Specifically, the language includes how much a child understands (receptive) and speaks (expressive), together with the child’s pragmatics, grammar, and how the child is using the language he or she has to communicate with others (Mody & Belliveau, 2013). Whereas, speech includes articulation, stuttering, lisps, volume, speed and etcetera (Mody & Belliveau, 2013). Additionally, in speech and language assessment practitioners are interested in how children use language socially such as to share interests, excitement and to ask for help (Mody & Belliveau, 2013). However, speech and language assessment can include pictures, toys, and games.

For this case, the

teacher has given this assessment to Azeem and conclude that he has delayed speech and difficulty in expressive language.

2.4 Motor skills assessment Motor skills assessment including fine (finger movements) and gross (large muscle movements) motor skills can also be crucial in determining if difficulties in these areas are causing downstream effects on learning and behaviour as well as adaptive functioning in ASD 4

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children (Jones, Gliga, Bedford, Charman, & Johnson, 2014). While not considered a key symptom of ASD, many children with ASD and other developmental disorders have difficulties with motor skills (Jones et al., 2014). For Azeem's case, these skills are generally assessed by the occupational therapist in the centre and conclude that he has difficulty in both motor skills, especially the fine motor skills.

2.5 Sensory sensitivities assessment Sensory differences are common in ASD. For this reason, parents will always be asked about whether their child has now or in the past overreacted or under-reacted to sound, touch and taste (McCormick, Hepburn, Young, & Rogers, 2016).

Likewise, when given an

opportunity to play with miniature toys such as cars, animals and household items, children with ASD usually focus on their sensory qualities like how the toys feel, reflect light, or what kind of noise the toys make rather than on the function (Steiner, Goldsmith, Snow, & Chawarska, 2012). Furthermore, problems with coordination or clumsiness are common because it can affect how the child manages tasks such as dressing, feeding, handwriting (McCormick et al., 2016). In this case, these sections have been assessed for Azeem in detail by an occupational therapist. Thus, the therapist mentioned that the difficulty in sensory sensitivities has affected his capability to handle those daily activities.

3.0 Diagnosis According to the American Psychiatric Association (2013), Azeem has met the diagnostic criteria of autism spectrum disorder (ASD). Therefore, the centre suspects that he has an ASD. Firstly, he has met the diagnostic criteria A since he has persistent deficits in social communication and social interaction across multiple contexts. Significantly, the 5

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diagnoses are reliable because it is based on multiple sources of information, including the observations of clinician and caregiver history. In detail, as discussed by the American Psychiatric Association (2013), deficits in social-emotional reciprocity including the ability to engage with others and share thoughts and feelings are obviously evident in young children with the disorder, who may demonstrate little or no initiation of social interaction and no sharing of emotions, together with reduced or absent imitation of others' behavior. For this case, Azeem does not have the ability to engage with others and share his thoughts and feelings. Especially, when he felt happy he will make the ‘ak, ak’ sound and also when he does not like the activities. This is because he does not know how to share his feelings with others. Moreover, Azeem shows the deficits in nonverbal communicative behaviours used for the social interaction. Specifically, according to the analysis of American Psychiatric Association (2013), their social interactions manifested absent use of eye contact, gestures, facial expressions and body orientation. As observed, Azeem does not show any eye contacts and facial expressions to the others. Additionally, in line with the analysis of American Psychiatric Association (2013), the early feature of autism spectrum disorder is impaired joint attention as manifested by a lack of pointing, showing, or bringing objects to share the interest with others, and failure to follow someone's pointing or eye gaze. These symptoms also can be seen in Azeem when he failed to follow the direction of the teacher point and he does not share his interest with others. Furthermore, he has difficulties in sharing imaginative play or in making friends. Likewise, when the teacher gives him the 5 minutes break time, he showed no interest in his peers and will not mix around with anyone in the centre. Meanwhile, he will only play his favourite toy and produced the ‘ak, ak’ sound. Accordingly, Azeem has met the criterion A in autism spectrum disorder. Furthermore, Azeem has met the diagnostic criteria B in which he shows restricted, repetitive patterns of behaviour, interests, and activities. This can be observed by the repetitive 6

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motor movements and the use of objects including simple motor stereotypies, lining up toys and bang objects (American Psychiatric Association, 2013). For instance, he manifests the repetitive motor movements such as walking to and fro and using his hand to hit the toy repeatedly in order to produce the sound. In addition, according to the American Psychiatric Association (2013), the criteria B of autism spectrum disorder including highly restricted and fixated interests that are abnormal in intensity or focus such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests. Specifically, from our observation, Azeem will only play his favourite toy which is a blue car during his break time although he has given a variety of toys. Therefore, this shows that he has a strong attachment to his blue toy car. Apart from that, as claimed by the teacher, Azeem experiences hypo sensitivities to stimuli. As observed, the teacher always called his name two to three times and wave her hands to stimulate his senses. Also, the first session in the early morning was the sensory massage in which the teacher used a few types of objects with different textures on his limbs and also the mouth to increase his sensory sensitivities. Not only these, but Azeem also enjoy and seek all sorts of movement and can spin or swing for a long time without being dizzy or nauseated, especially he can play the swing for up to ten minutes non-stopping. Explicitly, according to the reason aforementioned, Azeem has met the criterion B in ASD and can be categorized in the second severity level in which he is requiring substantial support. Apart from that, as discussed by American Psychiatric Association (2013), symptoms of ASD 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. For this case, Azeem has met the criterion C in ASD. Specifically, as mentioned by the teacher, the behaviours and symptoms of ASD showed by Azeem can be observed during his early childhood. Besides that, he has delayed speech and language skills and repeated phrases. 7

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Henceforth, the symptoms mentioned above have caused clinically significant impairment in social, occupational, or other important areas of current functioning. However, according to our discussion with the teacher, Azeem does not have an intellectual disability. Therefore, based on the analysis of American Psychiatric Association (2013), criterion E in ASD noted that these disturbances are not better explained by intellectual developmental disorder or global developmental delay. For this reason, intellectual developmental disorder and ASD frequently co-occur. Hence, according to the analysis of American Psychiatric Association (2013), in order to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for a general developmental level. Upon the symptoms aforementioned, Azeem has met all the diagnosis criteria in ASD.

4.0 Etiology The etiology of autism spectrum disorder (ASD) has been a widely debated issue for several decades (Shaw, Sheth, Li, & Tomljenovic, 2014). However, the exact cause of autism is still unknown (Shaw et al., 2014). While no single cause has been identified, the research has suggested that ASD may be caused by genetic risk factors, environmental factors or neurobiological factors (Shaw et al., 2014). According to the studies of Pendergrass, Girirajan, and Selleck (2014), an investigation is conducted on the connection between genetic variation and ASD. Specifically, the result demonstrated that twin studies have indicated that ASD is highly heritable (Pendergrass, Girirajan, & Selleck, 2014). Notably, as claimed by Pendergrass, Girirajan, and Selleck (2014), not all children can be identified as having a genetic linkage or mutation that is obvious to family members. Moreover, findings in support of a genetic link include research results presented that ASD is more common in boys than girls are most probably because of the genetic differences associated with the X chromosome (Cop, Yurtbasi,

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Oner, & Munir, 2015). Additionally, in a study conducted by Cop at al. (2015), almost 20% of infants with an older biological sibling with ASD also developed ASD. Thus, the risk of developing ASD was greater if there was more than one older affected sibling. Besides that, investigation of environmental risk factors for ASD is a growing research field (Preiserowicz, 2015). Specifically, as analysed by Preiserowicz (2015), the increasing rates of ASD manifest that the potential for environmental exposure playing an important role in the etiology and/or heterogeneity of ASD. Hence, in accordance with the studies of Joshi, Percy, and Brown (2002), there is also a need for the exploration of gene-environment interactions. Significantly, these include lead and mercury poisoning, maternal alcohol consumption, drug abuse and smoking, and pre- or perinatal anoxia/asphyxia, as well as different types of in utero viral infections (Currenti, 2010; Buxbaum, 2009). Therefore, identifying both genetic variants concomitant with environmental exposure may provide an important understanding of the etiology of ASD. Apart from that, abnormalities in the genetic code may result in abnormal mechanisms for brain development, leading in turn to structural and functional brain abnormalities, cognitive and neurobiological abnormalities, and symptomatic behaviours (Ha, Sohn, Kim, Sim, & Cheon, 2015). In detail, based on the studies of Ha et al. (2015), problems with genetic code development involving multiple brain areas, including frontal and anterior temporal lobes, caudate, and cerebellum. Consequently, there are concerns that cases of autism might be associated with neurobiological factors.

5.0 Treatment recommendations In accordance with the studies of Wirth and Gabor (2016), no cure exists for ASD and there is no one-size-fits-all treatment. For this reason, the primary goals of the treatment are 9

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to maximize the child's ultimate functional independence and the quality of life by minimizing the core ASD features, facilitating development and learning, promoting socialization, reducing maladaptive behaviours, educating and supporting families (DeFilippis & Wagner, 2016). Therefore, early intervention during the preschool years can help the children to learn critical social, communication, functional and behavioural skills. Significantly, there is a wide range of psychosocial interventions that have been developed targeting both the core symptoms and associated symptoms of ASD (DeFilippis & Wagner, 2016). However, the centre is currently using discrete trial training (DTT), occupational therapy and sensory integration therapy in Azeem’s lesson plan. Therefore, we suggest several options that may suit Azeem, including applied behaviour analysis (ABA), pivotal response training (PRT), and to continue discrete trial training (DTT), occupational therapy and sensory integration therapy.

5.1 Discrete trial training (DTT) Discrete trial teaching (DTT) is one of the backbones of applied behaviour analysis (ABA) based interventions (Leaf, Cihon, Leaf, McEachin, & Taubman, 2017). It is defined as a systematic type of intervention which is frequently included with other treatment procedures to teach individuals diagnosed with ASD a wide range of skills (Leaf et al., 2017). When applying this intervention, a discriminative stimulus is displayed, the child responds, and then the child receives a reward based on the response (Leaf et al., 2017). In this case, the teacher has applied this intervention in which she always praises Azeem once he has completed his routines. For example, the teacher will use simple praise words including a good job, great, and yes to reward his correct answers and behaviours. Besides that, DTT approaches are beneficial in establishing learning readiness by teaching foundation skills including attention, compliance, imitation, and discrimination learning, as well as a diversity of other skills (Leaf

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et al., 2017). Likewise, in Azeem's case, the teacher will request him for eyes contact and to high five after every routine. This is because the teacher wants him to pay attention to what he has accomplished. Also, she will make sure that Azeem has paid attention to his routine such as matching the puzzle, colour and number. Moreover, as analysed by Eikeseth, Smith and Klintwall (2014), DTT usually combines the use of errorless learning, shaping, modelling, prompting, facing, correction, and reinforcement to encourage skill acquisition. Specifically, according to Eikeseth, Smith and Klintwall (2014), it is well-suited for skills that can be taught in small and repeated steps. Additionally, research suggested that DTT can produce remarkable behavioural outcomes in the domains of language, motor skills, imitation and play, emotional expression, academics, and the reduction of self-stimulatory and aggressive behaviours (Eikeseth, Smith & Klintwall, 2014). Henceforth, we believe that this intervention can be a useful choice for Azeem in improving his language, motor skills and emotional expression.

5.2 Occupational therapy and sensory integration therapy Occupational therapy generally is provided to promote the development of self-care skills such as dressing, manipulating fasteners, using utensils, and personal hygiene as well as academic skills including cutting with scissors and writing (Nouri & Pihlgren, 2018). Moreover, occupational therapists may assist in promoting the development of play skills, reorganize classroom materials and routines to improve attention, organization, and providing prevocational training (Nouri & Pihlgren, 2018). However, sensory integration (SI) therapy generally is used alone or as part of a broader program of occupational therapy for children with ASD (Pfeiffer, Koenig, Kinnealey, Sheppard, & Henderson, 2011). Significantly, the goal of SI therapy is not to teach specific skills or behaviours but to remediate deficits in neurologic processing and integration of sensory information to allow the child to interact with the

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environment in a more adaptive way (Pfeiffer et al., 2011). For Azeem’s case, we recognized that the teacher works to develop fine motor skills including holding a pen and a pair of scissors and daily living skills such as dressing and toileting. Based on our observation, the teacher will ask him to cut the paper with scissors and learn how to sort objects by shape and colour. Also, he was able to separate small things into a respective container without the assistant of the teacher. Thus, this can be beneficial to remove his barriers in learning and help him to become calmer and more focused. Apart from that, sensory integration therapy helps the person deal with sensory information, like sights, sounds, and smells (Cermak, Curtin, & Bandini, 2010). Also, it could help a child who is bothered by certain sounds or does not like to be touched (Cermak, Curtin, & Bandini, 2010). Thus, based on our observation on Azeem, the teacher requests him to play the sand in the sand tray and plasticine. However, he does not like to get involved in that section as he felt disgusting when touching on it. Therefore, we think that occupational therapy and sensory integration therapy is useful for Azeem.

5.3 Applied behaviour analysis (ABA) Applied behaviour analysis (ABA) is a treatment based on theories of learning and operant conditioning (DeFilippis & Wagner, 2016). As claimed by Lindgren and Doobay (2011), it involves specific intervention targets, together with positive reinforcement such as verbal praise, tokens, or edible rewards, with the repetition of learning-trials which is a significant element.

Significantly, as suggested by and Doobay (2011), intensive ABA

intervention can cause remarkable effects, including almost half of the children receiving this treatment gaining significant IQ points and being mainstreamed into regular classes. Thus, in our opinion, the teacher may give more positive reinforcements instead of instructions to motivate Azeem. Furthermore, ABA focuses on both prevention and remediation of the

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problem behaviour (Little, Kriz, & Thielke, 2011). Likewise, as analysed by Little, Kriz, and Thielke (2011), ABA treatment is applied to increase and retain the desirable adaptive behaviours by reducing the interfering maladaptive behaviours or narrow the conditions under which they appear. In addition, ABA is a method of teaching new skills and abilities along with generalizing behaviours to new environments or circumstances (Little, Kriz, & Thielke, 2011). In this case, we realized that Azeem has improved in which he tried to repeat what the teacher has said. Therefore, after the observations on Azeem, we think that this method may useful in increasing his performance of daily activities such as wearing his pants along with gaining the language abilities. Not only increase his adaptive behaviour, but also decrease his maladaptive behaviour such as hitting himself and shouting. Notably, in accordance with the studies of Rogers and Vismara (2008), research demonstrated that the best outcomes happen when ABA is initiated early in development in which preferably prior to 5 years of age. Additionally, as analysed by Shenoy, Indla, and Reddy (2017), children who receive early intensive behavioural treatment have been shown to make significant, sustained gains in IQ, language, academic performance, and adaptive together with some measures of social behaviour, and their outcomes have been remarkably better than those of children in other groups. Thus, in our perspectives, Azeem can start this treatment early to improve his conditions since he is only a five years old boy.

5.4 Pivotal response training (PRT) Pivotal response treatment (PRT) is an evidence-based behavioural intervention based on applied behaviour analysis principles designed to improve social communication skills in individuals with ASD (Lei & Ventola, 2017). PRT builds on the initiative and interests of the child in which makes it particularly effective in developing communication, play, and social

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behaviours (Lei & Ventola, 2017). In general, PRT emphasis on using several numbers of strategies to help in increasing the children's motivation during the intervention, such as using a variety of child-chosen activities that are intrinsically motivating to each child (Lei & Ventola, 2017). Additionally, according to the studies of Daw (2013), this approach also focuses on interspersing maintenance and acquisition tasks to strengthen children’s exposure to wellestablished response-reinforcer contingency. Apart from that, research has demonstrated the effectiveness of PRT in increasing motivation and improving language and play skills among ASD children (Daw, 2013). Furthermore, this intervention can be applied to preschool-aged children through adults with mild cognitive impairments and with those who have at least a minimal level of receptive and expressive language (Daw, 2013).

Therefore, we have

suggested that Azeem is suitable for this approach. For this reason, as stated by the teacher, Azeem has difficulty in the receptive and expressive language in which he will not give any reaction to the teacher verbally when she calls him. Also, based on our observation, we realized that he likes those activities with matching and pairing puzzle and colourful objects. Therefore, we think the teacher may focus on and emphasize more in this domain.

6.0 Prognosis Children who are diagnosed with autism face a great range of outcomes. Specifically, in line with the analysis of Morris (2008), some children are reported to have learned speech and/or writing, self-care, and social skills on their own. Whereas, others experience an apparently miraculous "recovery" and begin behaving in a way that is basically indistinguishable from the way neurotypical children behave (Morris, 2008). However, intensive early intervention stresses the importance of parental involvement from the start (Fernell, Eriksson, & Gillberg, 2013). For this reason, some children with autism become

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mainstream after years of hard work and intensive training (Fernell, Eriksson, & Gillberg, 2013). Some develop slowly, but never lose their diagnoses. Thus, there are a few who never move beyond a level of functioning that society perceives as 'low', yet others are fairly typical during childhood and report becoming "more autistic" in adulthood (Fernell, Eriksson, & Gillberg, 2013). As a result, early diagnosis and intervention are consistently acted as the major element in improving a child's long-term future. Based on the research of Vivanti, Prior, Williams, and Dissanayake (2014), while some people see early intervention as significant for autism, the prognosis is also less certain the younger the child is. Markedly, children with autism, like those with learning disabilities, have been realized to cognitively develop throughout their lives. Hence, as mentioned by Vivanti et al. (2014), most children with autism lack social support, meaningful relationships, future employment opportunities or self-determination. However, children recover occasionally and sometimes after intensive treatment and sometimes not since it is not known how often this happens. Although core difficulties remain, symptoms often become less severe in later childhood. Henceforth, there is a wide range of consensus in the medical community to the effect that autistic behaviours can be improved through training, medical or educational interventions, though there is difficulty finding consensus on treatment procedure and goals (Mukaddes, Tutkunkardas, Sari, Aydin, & Kozanoglu, 2014).

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Leaf, J. B., Cihon, J. H., Leaf, R., McEachin, J., & Taubman, M. (2017). A progressive approach to discrete trial teaching: Some current guidelines. International Electronic Journal of Elementary Education, 9 (2), 361-372. Lei, J., & Ventola, P. (2017). Pivotal response treatment for autism spectrum disorder: Current perspectives. Neuropsychiatric Disease and Treatment, 13, 1613. Lindgren, S., & Doobay, A. (2011). Evidence-based interventions for autism spectrum disorders. The University of Iowa, Iowa. Retrieved from http://www.interventionsunlimited.com/editoruploads/files/Iowa%20DHS%20Autism %20Interventions%206-10-11.pdf Little, A., Kriz, H., & Thielke, A. (2011). Applied behavioral analysis and other behavioral therapies for the treatment of autism spectrum disorder. Oregon Health and Science University. Retrieved from https://www.hca.wa.gov/assets/program/ABA%20and%20Other%20Therapies%20for %20ASD_Final_06_10_2011.pdf Long, C., Gurka, M. J., & Blackman, J. (2011). Cognitive skills of young children with and without autism spectrum disorder using the BSID-III. Autism Research and Treatment, 759289. McCormick, C., Hepburn, S., Young, G. S., & Rogers, S. J. (2016). Sensory symptoms in children with autism spectrum disorder, other developmental disorders and typical development: A longitudinal study. Autism, 20 (5), 572-579. Mody, M., & Belliveau, J. W. (2013). Speech and language impairments in autism: Insights from behavior and neuroimaging. North American Journal of Medicine & Science, 5 (3), 157. Morris, B. (2008). Autism spectrum disorder fact sheets: Long term outcome with autism. Autism Organization: Synapse Reconnecting Lives. Retrieved from http://www.autism-help.org/autism-prognosis-long-term.htm. Mukaddes, N. M., Tutkunkardas, M. D., Sari, O., Aydin, A., & Kozanoglu, P. (2014). Characteristics of children who lost the diagnosis of autism: A sample from Istanbul, Turkey. Autism Research and Treatment. Nouri, A., & Pihlgren, A. (2018). Socratic seminars for students with autism spectrum disorders. Dialogic Pedagogy, 6. Pendergrass, S, S., Girirajan, S., & Selleck, S. (2014). Uncovering the etiology of autism spectrum disorders: Genomics, bioinformatics, environment, data collection and exploration, and future possibilities. Biocomputing, 422-426. Pfeiffer, B. A., Koenig, K., Kinnealey, M., Sheppard, M., & Henderson, L. (2011). Effectiveness of sensory integration interventions in children with autism spectrum disorders: A pilot study. American Journal of Occupational Therapy, 65 (1), 76-85. Preiserowicz, R. (2015). What are the possible causes for autism spectrum disorder?. The Science Journal of the Lander College of Arts and Sciences, 9 (1), 15.

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Rogers, S. J., & Vismara, L. A. (2008). Evidence-based comprehensive treatments for early autism. Journal of Clinical Child & Adolescent Psychology, 37 (1), 8-38. Shaw, C. A., Sheth, S., Li, D., & Tomljenovic, L. (2014). Etiology of autism spectrum disorders: genes, environment, or both. OA Autism, 2 (2), 11. Shenoy, M., Indla, V., & Reddy, H. (2017). Comprehensive management of autism: Current evidence. Indian Journal of Psychological Medicine, 39 (6). Steiner, A. M., Goldsmith, T. R., Snow, A. V., & Chawarska, K. (2012). Practitioner’s guide to assessment of autism spectrum disorders in infants and toddlers. Journal of Autism and Developmental Disorders, 42 (6), 1183-1196. The Children's Hospital of Philadelphia. (2016). Elements of an evaluation for autism spectrum disorder. Retrieved from https://www.carautismroadmap.org/elements-ofan-evaluation-for-an-autism-spectrum-disorder/ Vivanti, G., Prior, M., Williams, K., & Dissanayake, C. (2014). Predictors of outcomes in autism early intervention: Why don’t we know more?. Frontiers in Pediatrics, 2, 58. Wirth, B., & Gabor, V. (2016). Treatment for children with autism spectrum disorders and the EPSDT benefit. A Publication of the National for State Health Policy, 1-8.

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