Parenting) Autism - Symptoms, Causes, Assessment, And Treatment

AUTISM SYMPTOMS, CAUSES, ASSESSMENT, AND TREATMENT

What is Autism? Definition Autism or Autistic Disorder is a pervasive developmental disorder that affects all of mental development. It looks very different at different ages and certain features do not become apparent until later. Autism is probably present at birth but is often not identified until the child fails to develop communicative language at about 2 years of age. 70% of children with Autism have IQ's below 70; and 11% have IQ's above 85. Those individuals who are most developmentally delayed are usually also most autistic. As with normally developing children no two children with Autism are alike and the differential diagnosis of such disorders as Autism, Asperger's Syndrome, Nonverbal Learning Disability (NLD), Pervasive Developmental Disorder (PDD), and severe communication disorder can be difficult. It is believed by many researchers that the fundamental deficit that is seen in autistic children is a "mind blindness" or a lack of a theory of mind or the capacity to understand that other people think and feel the same way as they do. This deficit is believed to contribute to the difficulty that autistic children have in imitating another person's reactions, particularly their body movements, and particularly if the content of the actions is affective. Several studies have also found specific deficits in autistic children's perception and understanding of emotions.

“Autism or Autistic Disorder is a pervasive developmental disorder that affects all of mental development.”

Children with Autism have three primary distinguishing features: · · ·

Impairments in social interaction (are not interested in peer interactions and may show little eye-to-eye contact and lack of sharing with others). Impairments in communication (delays in or lack of spoken language). Repetitive and stereotypic behaviours, interests and activities (may show behaviours such as hand flapping, spinning objects, and rituals).

Incidence 10 - 15 per 10,000 children are autistic and an additional 12 - 20 per 10,000 have autistic-like features. Three boys to one girl have the disorder.

Diagnosis The DSM-IV-TR (2000) has identified Autistic Disorder as one disorder under the wider category of Pervasive Developmental Disorders. Under the broader category there are other disorders included such as Asperger's Syndrome, Rett's Disorder, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder (Not Otherwise Specified). DSM-IV-TR has identified the following diagnostic criteria for the Autistic Disorder.

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AUTISM Diagnostic Criteria

A.

A total of six or more items from (1), (2), and (3) with at least two from (1), and one each from (2) and (3). (1)

qualitative impairment in social interactions, as manifested by at least two of the following: (a) (b) (c) (d)

(2)

qualitative impairment in communication as manifested by at least one of the following: (a)

(b) (c) (d) (3)

marked impairment in the use of multiple nonverbal behaviours such as eye-to-eye gaze, facialexpression, body postures, and gestures to regulate social interaction failure to develop peer relationships appropriate to develop mental level a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g. by lack of showing, bringing, or pointing out objects of interest) lack of social or emotional reciprocity

delay in, or total lack of, the development of spoken lan guage (not accompanied by an attempt to compensate through alter native modes of communication such as gestures and mime) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others stereotyped and repetitive use of language or idiosyncratic language lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level

“10 - 15 per 10,000 children are autistic...”

restricted repetitive and stereotyped patterns of behaviour, interests, and activities as manifested by at least one of the following: (a) (b) (c) (d)

encompassing preoccupation with one or more stereotyped and restricted patterns of interest that isabnormal either in intensity or focus apparently inflexible adherence to specific, nonfunctional routines or rituals stereotyped and repetitive motor mannerisms (e.g. hand or finger flap ping or twisting, or complex whole-body movements) persistent preoccupation with parts of objects

B.

Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play

C.

The disturbance is not better accounted for by Rett's Disorder or Childhood Distintegrative Disorder.

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) (p. 79).Washington, D.C.: American Psychiatric Association. 2

AUTISM Diagnostic Criteria

It is still not clear what precise deficits underlie Autistic Disorders but researchers have got much closer to understanding them in the last five years. This has mainly occurred because the latest research has compared autistic children to other children with the same IQ and chronological age. Deficits appear to be very selective and are not the same in all children with Autism.

Other Symptoms That may Be Present For Some Children · · · · · · · · · · · · · · · · · · · · · · · · · · ·

Gross and sustained impairment of emotional relationships with people, aloofness and/or empty symbiotic clinging. Apparent unawareness of their own personal identity (e.g. posturing, self-mutilation, and failure to use "I"). Obsessive use of and preoccupation with objects without regard to their functions. “It is still not clear Resistance to change in the environment and a striving to maintain sameness. what precise deficits Excessive, diminished, or unpredictable responses to sensory stimuli. underlie Autistic Acute, excessive, and illogical anxiety especially precipitated by change. Speech may have been lost or never acquired. Disorders but May use echolalia and certain idiosyncratic words. researchers have got Distortion in mobility patterns such as bizarre postures or ritualistic manner much closer to isms, strange gestures and toe walking. understanding them in Serious retardation with possible islets of normal or near normal intelligence and sometimes exceptional functioning in very isolated areas. the last five years.” Poor concentration, short attention span and distractibility. Minimal social and self help behaviours. May place him/herself in danger by, for example, not watching while crossing the road. Does not show mutual sharing of interests, activities, and emotions with others, particularly other children. Does not understand the perspective of others. May be aggressive if frustrated or if a child comes too close to their space. May line up toys and not be interested in their function. May seem unaware of what is going on around them. May wander off in shopping malls and in parking lots seemingly without a sense that they are alone. Mainly engages in interaction in order to get what they want. May "use" a person's arm in order to get what they want or to do something they cannot do. This has been called "hand leading" and is used instead of pointing. Does not use the emotions of others or "social referencing" in order to decide how to act. Does not follow through on the requests of others because they are really not understood and the child is doing what he wants to do. May enjoy physical contact with parents and other caregivers if it is when they want it. May not seek out comfort when upset or hurt. Show little desire to imitate or copy another person's behaviour. May show self-injurious behaviour.

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AUTISM Causes

Causes Exactly what causes Autism is unknown although it is believed to be a neurological condition. Medical conditions that could be causal are found in only about 5-10% of cases.

Genetic Component It seems likely that a predisposition to Autism is inherited. The evidence of the heritability of Autism comes from twin and family studies. In twin studies, unusually high rates of Autism are found in identical twins, and very low rates in fraternal or non-identical twins. Studies of families have indicated that 2-6% of the siblings of autistic children are also autistic, and that 8% of the extended families will include another member who is autistic. Family studies also reveal an increased prevalence of mental retardation and cognitive difficulties in the siblings of autistic children especially those who are mentally retarded themselves. This suggests that what may be inherited is not an "Autism gene" but rather a nonspecific factor which increases the likelihood of various cognitive problems including Autism.

Neurobiological Difficulties It is believed that Autism may be related to damage to the prefrontal cortex and limbic region of the brain and to the connections between the two regions. The most consistent findings are of brain stem and cerebellum abnormalities. P.E.T. scans with Autistic children show the location of problems to be in these areas of the brain. Adults with this kind of brain damage, as a result of accident or stroke, display similar difficulties as autistic individuals. There is some indication that the brains of children with Autism may have increased cell density suggesting that the cells did not get pruned back as they do in normal development. Other researchers have found that this is particularly true within the dopamine system suggesting that there may be an excess of dopamine which could contribute to an overactive system. Studies of glucose metabolism and blood flow have failed to reveal consistent global or regional abnormalities, although correlational studies do show some promise.

“It seems likely that a predisposition to Autism is inherited.”

Developmental History The developmental history of autistic children seldom reveals medical conditions that can be linked to the disorder. However, certain other illnesses place children at risk for developing Autism. These are neurofibromatosis, tuberous sclerosis, and fragile X syndrome. Many children with Autism (approximately one fifth to one third) develop seizures. Most of these occur in lower functioning individuals and usually develop in later childhood or adolescence. Many studies have shown that the number of perinatal problems experienced by autistic children are exceptionally high including: difficult delivery, infantile seizures, delayed breathing and neonatal convulsions. Some children appear to have normal development earlier and only show the symptoms of Autism in the second year of life. There have been two explanations given for this: (1) the child did show problems earlier but they only became obvious when speech failed to develop and the pressure for socialization was greater, or (2) the child was born with a vulnerability to acquiring the syndrome and it was triggered by a virus or other insult.

Environmental Factors As mentioned previously in a very few cases of Autism a viral infection in a young child preceded the onset of the symptoms of Autism, before which there was a period of apparently normal development. There are also some cases where infections occurred in the mother at an early stage of pregnancy. No other links to environmental conditions have been found. 4

AUTISM Development

Development Infancy In general, unless there is mental retardation, the signs of Autism may not be obvious until the second year of life when language does not develop normally and the child does not show any interest in playing with other children. Stereotypic behaviours may also develop at this time. However, even in early infancy some signs of difficulties may be observable. See the following chart for a list of these signs

Signs in Infancy (first year) MOTOR Inactive: · Flaccid muscle tone · Rarely cries Or Irritable: · Inconsolable · Only soothed when in constant motion · Limp Or Motorically disorganized: · May be very active · Have poor motor planning in reaching for objects

PERCEPTUAL Unusually sensitive to sensory stimuli Auditory: · Appears deaf to voice but jolts or panics at environmental sounds Tactile: · Refuses food with rough texture · Adverse reaction to wool fabrics and labels, etc. · Prefers smooth surfaces Visual: · Sensitive to light · May panic at change in illumination · Preoccupied in observing own hand and finger movements

SOCIAL-E EMOTIONAL Unresponsive: · No social smile · Avoidance of eye contact when held · Fleeting eye contact at a distance · Lack of anticipatory response to being picked up · Seems not to like being held or hugged · Seems content left alone · Does not visually follow the coming and going of primary caregiver · Does not play peek-aboo or patty-cake or wave bye-bye · Fails to show normal 8month stranger anxiety · Does not respond to social bids from caregiver

LANGUAGE

MENTAL REPRESENTATIONAL

Delayed or absent coo or expressive socialization

Decreased visual pursuit of objects and people

Failure to imitate sounds, words, or gestures

Object permanence develops slowly or stops at age 2 or 3 years so child does not develop capacity for retaining a memory of object or person or for searching for them

Little communication or use of gestures Speech delayed or shows precocious advances followed by failure to use previously learned words Use eye contact when interacting Does not point to object or hold up an object to show it to caregiver

Fails to form strong personal attachments

Early Childhood It is usually in the second year of life that signs of Autism become most obvious and assessment is requested in order to determine the reason or cause of the symptoms. Some of the signs that become obvious at this time are outlined below.

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AUTISM Development

Signs in Second and Third Year MOTOR Toe walking Rocking Head banging Whirling without dizziness Perseverative movements such as spinning or finger posturing

PERCEPTUAL

SOCIAL-E EMOTIONAL

Withdraws from environmental stimulation

Moves adult's hand like a tool

Echolalia or repeating what is said

Engages in self stimulation

Insists on sameness and ritualizes routines

Delayed echolalia unrelated to social context

Preoccupied with spinning and shiny objects

Socialization:

Pronoun reversals

· Does not respond to social bids · Does not smile to praise or a smile of someone else · Does not engage in reciprocal and back and forth play · Does not imitate the actions of others · Does not repeat actions to get attention or to show off for caregivers · Does not show interest in other children or want to play alongside them · Does not show others a object to show interest

Voice atonal, hollow and arhythmic

Suddenly ceases and activity and stares into space. Often with hyperextension of the neck Respond inconsistently to sounds (e.g. seems deaf) Show unusual visual interests (e.g.spinning objects, "studying" objects

LANGUAGE

Does not use language or gestures to communicate Seems not to understand what is being said or gestured

MENTAL REPRESENTATIONAL Play: · No imaginative play· Little appropriate use of toys · Does not engage in play sequences with toys · Does not play with dolls Preoccupied with impersonal, invariant information (e.g. television commercials) May engage in repetitive play activities (e.g. lining up toys and opening or closing cupboards)

Does not use eye contact to communicate

Older Children, Adolescents, and Adults IImprovements in behaviour and compliance are usually evident after 5 years of age. The biggest change is most often a decrease in social and emotional problems. The children become more affectionate and sociable, less resistant to change, less given to needless fears, more aware of real dangers, and somewhat better behaved in public. However, the cognitive difficulties that are a part of the disorder usually continue although early intervention with children with the disorder has been shown to be helpful. Long term prognosis is generally poor for children with Autism as only about 8% in most follow-up studies become employable and live independently. The best indicators of success in later life are having an IQ of over 85, developing speech before age 5, not having any additional identifiable neurological difficulties, and not developing seizures in late childhood or adolescence

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AUTISM Diagnosis and Assessment

Diagnosis To meet criteria for a diagnosis of Autistic Disorder a child must meet the 3 conditions outlined in the DSM-IV-TR. These are: 6 items in the areas of: impairment in social interaction, communication, or in having repetitive and stereotyped patterns of behaviour; or delays in social interaction, language, and symbolic or imaginative play which are not accounted for by Rett's Disorder or Childhood Disintegrative Disorder. Other observation schedules and questionnaires can also be used to make the diagnosis. Although the symptoms of Autism are evident by 2 years of age or before, the differential diagnosis of Autism can still be difficult especially making a distinction between such other disorders as severe communication disorder, Pervasive Developmental Disorder, and Nonverbal Learning Disability (NLD). Testing children with Autism can be very challenging as they are usually not interested or able to follow or imitate the examiner's instructions and demonstrations of certain tasks. Also if children have behavioural difficulties or find strange places upsetting they may refuse items that they could usually complete. For this reason it is critically important to obtain information from a variety of settings and respondents.

Assessment Assessment needs to consider the following sources of information: · Clinical interviews with parents and teachers. · A developmental and medical history to see if there are any medical conditions or history of medical illness that could be contributing to the problems. · Assessment of hearing and vision. · If it has not been done a medical examination to rule out any other disorders. If there are soft neurological signs an examination by a neurologist would be important. · Tests of developmental level are important to determine the child's level of functioning in various areas of development. Because some children are very difficult to test, observation of their behaviours or questionnaires completed by the parents can be essential. · Observations of the child in different settings or situations. · Observations of parent-child interactions. · Use of tests which have been developed specifically to evaluate the child for autistic symptomatology. · Assessment for behaviour management.

“To meet criteria for a diagnosis of Autistic Disorder a child must meet the 3 conditions outlined in the DSM-IV-TR.“

Parent Interviews or Questionnaires · Parent Interview for Autism (for parents of children under 6 years of age) · Vineland Adaptive Behavior Scales · Autism Diagnostic Interview Developmental Assessments · Diagnostic Inventory for Screening Children (D.I.S.C.) · Leiter International Performance Scale for children who are non-verbal · Bayley Scales of Infant Development · Wechsler Intelligence Scales can be used if the child's level of development is high enough Direct Assessments for Children with Autism · Diagnostic Checklist for Behavior-Disturbed Children · Autism Diagnostic Inventory · Autism Diagnostic Observation Schedule (ADOS) · Psychoeducational Profile for children 1 to 12 years of age who are functioning at a preschool level Observational Scales · Autism Behavior Checklist (ABC) (completed by teachers) · Childhood Autism Rating Scale (CARS) · Checklist for Autism in Toddlers · Behavior Observation System (free play observation procedure) 7

AUTISM References

References American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, D.C.: American Psychiatric Association. Baron-Cohen, S., Cox, A., Baird, G., Swettenham, J., Nightingdale, N., Morgan, K., Auriol, D., & Charman, T. (1996). Psychological markers in the detection of autism in infancy in a large population. British Journal of Psychiatry, 168, 158-163. Cohen, D., & Volkmar, F. (Eds.)(1997). Handbook of autism and pervasive developmental disorder. (2nd ed.). N.Y.: John Wiley. Kranowitz, C.S. (1998). The out-of-sync child: Recognizing and coping with sensory integration dysfunction. New York: Perigree Book. Lord, C., & Risi, S. (2000). Diagnosis of autism spectrum disorder in young children. In A.M. Weterby & B.M.Prizant (Eds.). Autism spectrum disorders: A transactional developmental perspective (pp. 11-30). Baltimore: Paul Brookes Pub. Co. Lord, C., Rutter, M., Divare, P.C., & Risis, P. (1999). Autism Diagnosis Observation Schedule-WPS Edition (ADOS-WPS). Los Angeles: Western Psychological Services. Mesibov, G.B., Adams, L.W., & Klinger, L.G. (1997). Autism understanding the disorder. New York: Plenum Press. Rogers, S.J., & Benneto, L. (2000). Intersubjectivity in autism: The roles of imitation and executive function. In A.M. Wetherby & B.M.Prizant (Eds.). Autism spectrum disorders: A transactional developmental perspective (pp. 79-108). Baltimore: Paul Brookes Pub. Co. Schopler, E., Reichler, R.J., & Renner, B. R. (1986). The Childhood Autism Rating Scale (CARS) for diagnostic screening and classification of autism. New York: Irvington. Siegel, B. (1996). The world of the autistic child: Understanding and treating autistic spectrum disorders. New York: Oxford University Press. Weatherby, A.M., & Prizant, B.M. (2000). Autism spectrum disorders: A transactional developmental perspective. Vol. 9, Communication and Language Intervention Series. Baltimore: Paul Brookes Pub. Co. Wing, L. (1998). Classification and diagnosis - Looking at the complexities involved. Communication, 15-18. ZERO TO THREE/National Center for Clinical Infant Programs (1994). Diagnostic classification 0 -3 diagnostic classification of mental health and developmental disorders of infancy and early childhood. Arlington, VA: ZERO TO THREE.

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AUTISM TREATMENT

TREATMENT Definition Autism or Autistic Disorder is a pervasive developmental disorder that affects all of mental development. For further information on the diagnosis of Autism refer to the sections on “Symptoms, Causes and Assessment”. Children with Autism have three primary distinguishing features: · · ·

Impairment in social interactions. Impairment in communication. Repetitive and stereotypic behaviours, interests, and activities.

Treatment for children with Autism may be one or more of the following and may vary depending on the intellectual capacity of the child. Treatments that may be used include: · · · · · · · · ·

Applied behaviour analysis (ABA) Sensory integration therapy Auditory integration therapy Interactive approaches Music therapy Music interaction therapy Using megavitamins Medication Teaching the child to mind-read

“Applied Behaviour Analysis (ABA) is based on the view that autism is a neurological disorder which causes a number of deficits in behavioural responses.”

These forms of treatment are briefly described below and comments made on their effectiveness.

Applied Behaviour Analysis (ABA) Applied Behaviour Analysis (ABA) is based on the view that autism is a neurological disorder which causes a number of deficits in behavioural responses. Using Skinnarian operant conditioning the approach aims to increase adaptive behaviour (such as eye contact, language, self help skills) and decrease inappropriate behaviour (such as stereotypic behaviours and aggression). It works through reinforcement, punishment, shaping, fading, generalizing, extinction, etc. of the child's behaviour so he learns what is expected of him. Behaviours are broken down into small steps, and each step is taught (usually on one-to-one) by giving the child consistent cues that are faded out as soon as possible, so the child learns to respond to similar cues in the natural environment. In order to enhance motivation, teaching sessions are made as much fun as possible and tangible reinforcements are used such as toys or Smarties. The reinforcers are presented at a fast rate initially and then faded to intermittent reinforcement in order to sustain the behaviour. As the sessions progress the tangible reinforcements are gradually replaced by social reinforcers such as praise. Parents are included in the treatment so it can be carried over into the home and school ensuring that children will be consistently reinforced and will be able to able to use their new skills in different settings. Of all the interventions used with Autism research has shown it to be the most effective, especially for young children. It has been shown to result in integration into normal classrooms and to normal functioning for some children.

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AUTISM TREATMENT

Sensory Integration Therapy Children with Autism have difficulty processing stimulation from the environment that contributes to their over- or under-arousal by normal stimulation in the environment. This can explain the hypersensitivities or sensory defensiveness to touch, loud noises, bright lights, and certain food textures that are often found with these children. These contribute to their ritualistic and stereotypic behaviours such as body-rocking and spinning objects. It may also explain some of their withdrawal from closeness to human contact that children with Autism display although it is not believed to be the primary explanation. Sensory integration is a one-to-one therapy usually administered by an occupational therapist, that involves body massaging, swinging from a hammock, rocking, jumping on bouncy surfaces, climbing and crawling on special apparatus, or spinning on special chairs. Another related approach that is used with children who show extreme sensory defensiveness has been to apply rapid and firm pressure to the arms, hands, back, legs, and feet with a non-scratching brush with many bristles. A special brush is used which is a plastic surgical “Children with Autism scrub brush. The brushing is followed by gentle joint compression to the shoulders, elbows, wrists, hips, knees, ankles, and sometimes fingers and feet. It needs to be have difficulty processing repeated frequently throughout the day. Clear evidence for the effectiveness of the stimulation from the treatment is lacking although studies by its originator A. Jean Ayres suggest that it can reduce certain behaviours and increase some positive behaviours. environment that Auditory Integration Therapy Auditory Integration Therapy (AI) assumes that sensitivity to sounds causes aggression and impairs the Autistic child's interactions with others. The purpose of the therapy is to reduce this sensitivity so that their learning and especially their language will improve. It is hoped that by reducing auditory sensitivity, behaviour and learning, especially of language will improve. The therapy is conducted over about 2 weeks and the child spends 10 hours over the 2 weeks listening to music played through a machine that filters out frequencies to which they are sensitive. During this time it is suggested that all other treatment be discontinued. No scientific studies have been conducted although parent reports have indicated that children who receive the treatment have a reduced rate of behaviour problems and understand language better than children who received a placebo.

contributes to their overor under-arousal by normal stimulation in the environment.”

Interactive Approaches Stanley Greenspan and Serena Weider are the most well known advocates of using play to increase the functioning capacity and interactions of children with Autism. Children with Autism have little appropriate use of play objects and usually do not engage in pretend play. The treatment (called Floor Time) can take place in a room with toys that can be used to stimulate imaginative play including cars, animals, dolls, doll furniture, trains, etc. It can also be used throughout the day when the child is doing something he is interested in. The child's parent is usually included in the session and is encouraged by the therapist to carry out the following: 1. 2. 3.

Follow the lead of the child in whatever they are doing with the play and make it interactive. The interaction should not be interrupted as long as the child is enjoying it and wants to continue. Treat all the child's behaviour as if it is intentional and purposeful even though it may seem random and purposeless (e.g. the child is just picking up and dropping objects or may run around aimlessly). If the child is requesting something, indicating you do not know what he means will help extend the

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AUTISM TREATMENT

4. 5. 6. 7.

8. 9.

Face the child and make sure that their actions are differentiated from your own and some times put your hand over the child's to help them do something instead of encouraging the child to lead with his hand over yours. Use surprise and novelty to capture the child's attention and interest so the child is compelled to respond such as using a musical box or a jack-in-the-box. Pursue the child until he responds and keep trying new approaches to get interaction. Use tickling, peek-a-boo, and rhymes such as This Little Piggy, Ring Around the Rosy and help the child join in the actions. Add new meanings to stereotypic play and add pretend human figures such as having the lined up cars or the train which is going round and round to pick up people and talk about the people in the train or lining up waiting for the bus or train. If the child becomes upset empathize with the feelings but do not give up on the interactions. Use every opportunity to expand on pretend play such as, for example, offering “Because pretend cups of tea or pretend keys to open doors.

Music therapy Many children with Autism enjoy music and often enjoy dancing to it and will "sing" along with the words. This allows the child a medium for non-verbal self-expression and can provide a channel for communication. It can also be used to form the basis for enjoyable interactions and a relationship.

children with Autism enjoy music so much it has been found to be useful to integrate both play and music.”

Music Interaction Therapy Because children with Autism enjoy music so much it has been found to be useful to integrate both play and music. A music therapist or a musician scaffolds the interaction between the child and his parent(s). Children who cannot speak and do not engage in interactions with their parents are provided with prolonged exposure to preverbal play patterns supported by the music. Through lap play, dancing together, tapping to the music, and joint attention supported by the music the social or interactional skills and timing skills important for language are developed. Using Megavitamins Megavitamins have also been used as well as different types of restricted diets such as gluten free and restricting certain food such as sugar, milk, eggs, and chocolate. Some researchers have claimed that the vitamins B-6 and magnesium have positive effects but there is little evidence that these approaches are helpful. Medication Because Autism is a neurobiological disorder researchers have been studying the effects of medication on the disorder. As yet, medications have been used to treat some of the symptoms of autism such as disruptive behaviours, aggression, and stereotypic behaviours but have not been able to increase adaptive behaviours such as language and imagination. Some medications that have been used include antipsychotics (such as risperidone), ritalin, and anti-depressants but they have had mixed results and some have had adverse side effects. Anti-depressants (particularly Selective Serotonin Reuptake Inhibitors, (SSRIs)) have been found to be helpful for children with high anxiety and sensitivity to various stimuli to calm them and reduce negative behaviours. SSRIs have also shown some benefit both in terms of reducing unwanted behaviour as well as in increasing prosocial behaviours. However, studies have involved small numbers of children and have not been double blind placebo controlled studies. 11

AUTISM TREATMENT

Teaching the Child to Mind-R Read Children with Autism have deficits or have not developed a theory of mind or the capacity for "mind-reading" and this is seen as at the basis of many of their difficulties with socialization, pretend play, communication, and understanding the emotions of another person that relate to their beliefs. This deficit can lead to insensitivity to other people's feelings, difficulty with making friends by reading their interests and intentions, and can lead to more elaborate difficulties such as problems with realizing they are being deceived. The program Teaching Children to Mind-Read was developed by Howlin, Baron-Cohen, and Hadwin and research has shown that the method has been successful in teaching children with Autism to learn specific mental state concepts and that the improvements were maintained long after the intervention ended. The program provides the material that can be used to teach. It involves three types of learning: (1) teaching the child “Children with Autism about emotions from recognizing facial expressions in photos such as happy, sad, mad, have deficits or have not and afraid up to being able to recognize what a person would be feeling from a sequence developed a theory of of pictures, (2) teaching the child about perspective-taking and how people see things mind or the capacity for differently both visually and on the basis of knowledge that they have, and (3) teaching "mind-reading" and this is children to pretend play at increasingly complex levels. Developmental Social-P Pragmatic (DPS) Approaches To Teaching Communication Developmental Social-Pragmatic (DPS) approaches emphasize the importance of focusing on the child's natural attempts for communication and use more natural activities and events as contexts to support the child's development of social communications. In other words they do not rely on scheduled activities or programs such as the ABA approach to enhance the behaviour. Developed by Prizant, Wetherby, and Rydell, the approaches use interactive-facilitative strategies to carry out the therapy and focus on aspects of both verbal and nonverbal behaviour. The interactive approach described above is similar in the principles that underlie the approaches. In summary the DPS approach uses the following: · · · · · · · ·

seen as at the basis of many of their difficulties with socialization, pretend play, communication, and understanding the emotions of another person that relate to their beliefs.”

Enhances spontaneous communication within a flexible schedule and varied interesting activities. Builds on multimodal communicative repertoires including speech, gestures, and alternative communication methods. Encourages turn taking and reciprocity in interactions. Encourages the child interacting in a number of social groups. Uses gestures and visual supports to help the child make sense of the communication rather than breaking down the tasks into small pieces. Emotional expression and affect sharing are seen as crucial to the interactive and learning process. The intervention starts from the developmental level that the child is at, sometimes starting from prespeech, or echolalia, and moving to more creative levels of language. Attempts are made to have the child seek out assistance in order to calm down and types of activity are provided that can help them to regulate the emotions.

Augmentative Communication Some children with Autism will not be learn to speak and will need to use augmentative and alternative communication supports. Some of the common forms of augmentative communication devices are: use of pictorial or written schedules to assist the child to understand the school schedule, teaching children manual signs that they can use to communicate certain needs, and the use of voice-output computer programs. These devices can all allow the child to communicate and to be communicated with. 12

AUTISM Summary and Conclusions

Summary and Conclusions With so many treatments available choosing which type of treatment would benefit an individual child can be very confusing and frustrating for parents who are often looking for a cure for their child. There are, however, some guidelines that can be used in making decisions: · ·

· · · · · · · · · ·

Treatments should start as early as possible and treatment received between 2 and 4 years can improve a child's skills considerably. Treatment needs to be different for different children depending on their IQ level (which can range from below 50 to 120 and above), whether aggressive behaviour and other stereotypic behaviour is a problem, whether the child has language, and their level of socialization and their capacity for warm interactions with other children. It is, therefore, important that the child has a thorough assessment in order to deter mine the most appropriate treatment combination. Treatment may need to be intense to begin with to get the gains that may be As well, treatment possible and many improvements have occurred when treatment has been needs to be given as intense. All teaching in the various therapies needs to be broken down into small early as possible and steps, so that complex skills are acquired gradually, as a sequence of separate be intense to be components (see ABA and improving mind reading especially). Teaching needs to pay attention to the child's interests and to build on them successful. (e.g. if a child loves trains use them as a subject to teach other words, math, and reading). Having a structured classroom to help contain the child's anxiety and nervous system arousal can be very helpful. Sensory integration therapy and use of exercise as a release is an important component of treatment. Using visual cues to reinforce learning as well as routines that the child follows (e.g. have the child look at pictures of the stages of having a bath before they have one). Avoiding using long strings of verbal information as the child will probably not be able to follow it. Skills need to be reinforced by rewards but when the child finds the intervention fun and pleasurable the influence of the rewards can be further enhanced. Teaching needs to begin at the level the child is at and not a level that would be expected given the child's age. However, for children with higher levels of functioning,individualized rather than pre-packaged teaching methods need to be applied. Family support is crucial to help parents deal with the demands of providing treatment.

to

In conclusion it is important to: use a combination of various treatment strategies including approaches that build a relationship with the child and enhance parent's relating with their child and behavioural approaches. As well, treatment needs to be given as early as possible and to be intense to be successful. Author: Sarah Landy Ph.D., Developmental Psychologist We recognize and thank the Government of Ontario for its generous financial support of this publication.

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AUTISM Bibliography

Bebko, J.M., Perry, A., & Bryson, S. (1996). Multiple method validation study of facilitated commuication: 11. Journal of Autism and Developmental Disorders, 26, 19-42. Cohen, D. & Volkmar, F. (Eds.). Handbook of autism and pervasive developmental disorder. (2nd ed.). N.Y. : John Wiley and Sons.Dawn, C., Wimproy, S., & Nash, S. (1999). Musical interaction therapy :Therapeutic play for children with autism. Child Language Teaching and Therapy, 15, 17-25. Dawson, G., & Osterling, J. (1997). Early intervention in autism. In M. J. Guralnick (Ed.). The effectiveness of early intervention. (pp. 307-326). Baltimore: Paul Brookes Pub.Co. Greenspan, S.I. (1997). Developmentally based psychotherapy. Madison, CT: International University Press. Greeenspan, S.I., & Wieder, S. (1998) The child with special needs: Intellectual and emotional growth. Reading, MA: Addison Wesley Longmans. Hanna, S., & Wilford, S. Floortime: Tuning in to each child. (Book and video). New York: Scholastic Inc. Hodgdon, L.A. (1995). Visual strategies for improving communication: Practical supports for school and home. Michigan: QuirkRoberts Publishing. Howlin, P., Baron-Cohen, S., & Hadwin, J. (1999). Teaching children with autism to mind-read: A practical guide. Chichester, West Sussex: John Wiley and Sons. Hurth, J., Shaw, E., Izeman, S., Whaley, K., & Rogers, S.J. (1999). Areas of agreement about effective practices among programs serving young children with autism spectrum disorders. Infants and Young Children, 12, 17-26. Levine, C. (1991 ). Fine motor dysfunction: Therapeutic strategies in the classroom. Tucson, AZ: Therapy Skill Builders. Lovass, O.I. (1981). Teaching developmentally disabled children: The "me" book. Baltimore: University Park Press. Lovass, O.I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3-9. Maurice, C. (1996). Behavioral interventions for young children with autism: A manual for parents and professionals. Austin, Texas: Pro-ed. Quill, K. (2000). Do-watch-listen-say: Social and communication intervention for children with autism. Baltimore: Paul Brookes Pub. Quill, K. (1995). Teaching children with autism: Strategies to enhance communication and socialization. Baltimore: Paul Brookes Pub. Co. Prizant, B.M., Schuler, A.L., Wetherby, A.M., & Rydell, P. (1997). Enhancing early language and communication: Language approaches. In D. Cohen & F. Volkmar (Eds.). Handbook of autism and pervasive developmental disorder. (2nd ed.). (pp. 572-605). New York: John Wiley & Sons. Schwartz, S., & Miller, J.(1987). Teaching communication skills to children with special needs: A guide for parent and teachers. Yack, E., Sutton, S., & Aquilla, P. (1998). Building bridges through sensory integration. Weston, Ont., Canada.

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