Unit1: Autism

1.1 Concept and definition of Autism

1.2 Assessment, teaching and curriculum for children and Adolescents with autism

1.3 Structured Teaching techniques

1.4 Skill training and Communication skills

1.5 Behavioural Problems, Intervention.

 

 

 

 

 

 

 

 

 

 

 

1.1 Concept and definition of Autism

Autism Spectrum Disorders (ASD) are complex neurological disorders that have a lifelong effect on the development of various abilities and skills. Helping students to achieve to their highest potential requires both an understanding of ASD and its characteristics, and the elements of successful program planning required to address them.

The term “spectrum” is used to recognize a range of disorders that include a continuum of developmental severity. The symptoms of ASD can range from mild to severe impairments in several areas of development. Many professionals in the medical, educational, and vocational fields are still discovering how ASD affects people and how to work effectively with individuals with ASD.

The Individuals with Disabilities Education Act (IDEA)

•      A developmental disability affecting verbal and non-verbal communication and social interaction,(Age<3).

•       Engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences.

The Americans with Disabilities Act of 1990 (ADA)

•      Autism is defined as a developmental disability significantly affecting verbal and non- verbal communication and social interaction, generally (< age 3), which adversely affects a child's educational performance

Classification

The most recent and updated version of the Diagnostic and Statistical Manual of Mental Disorders version 5 (DSM -5) of American Psychiatric Association has just a single category for the diagnosis of an autistic disorder – autism spectrum disorders, which include the following disorders that were previously discussed separately:

Autism or Autistic Disorder: Children who seem to have met most of the rigid criteria of a diagnosis of Autism are said to have Autism or Autistic Disorder. They have moderate to severe impairments in Social and Language skills, possess Repetitive Behaviors and Restricted Interests. Often the children and individuals with Autistic Disorder also have mental retardation and seizures.

Asperger’s Syndrome: Asperger Syndrome: AS, is the mildest form of Autism. It is found to have affected boys three times more in comparison with girls.

The most common symptoms of Asperger Syndrome are the children affected become excessively interested in a single subject or topic. They tend to find out and learn everything about their preferred subject and talk about it all the time. As compared with other form of Autism, children with Asperger have extremely good vocabulary however their social skills are markedly impaired and they are often awkward and uncoordinated.

It is also found that the children with Asperger’s Syndrome very often have normal or above normal IQ (Intelligence Quotient). As a result, many doctors address it as High-Functioning Autism. As children with AS enter into Childhood, they are at a high risk of developing Anxiety and Depression.

PDD-NOS (Pervasive Development Disorder, Not Otherwise Specified): PDD-NOS is a little complex syndrome to diagnose amongst children on the Autism Spectrum. Commonly children & individuals whose behavioral symptoms are more severe than Asperger’s Syndrome but less severe than Autistic Disorder are diagnosed as PDD-NOS.

No two children/individuals with PDD-NOS exhibit similar symptoms. This makes generalizing the disorder rather more complex. Commonly, children with PDD-NOS exhibit following symptoms:

Impaired social communication/interaction (similar to Autistic Disorder)

Better language/communication skills as compared to children with Autistic Disorder however these skills are not as good as of children with Asperger’s Syndrome

Lesser sensory dysfunction as a result fewer repetitive behaviors

Rett Syndrome : Rett Syndrome is severe form of Autism and it mostly occurs in girls. It is mostly caused by a genetic mutation wherein the mutation occurs randomly and has no inherited significance. It is a rare syndrome affecting about one in 10,000-15,000 girls.

In this syndrome, girls aging between 6 to 18 months of age regress marginally and lose linguistic and social skills. They habitually wring hands and develop coordination problems. Head growth slows down significantly and by the age of two their head appears to be far below normal. The treatment of Rett Syndrome focuses mostly on physical therapy and speech therapy to improve function.

Child Disintegrative Disorder : It is the least common and most severe form of Autism Spectrum Disorder. In CDD, the child rapidly loses multiple areas of function between the ages of 2 to 4 years of age. This regression takes place in social skills, linguistic skills as well as in intellectual abilities.

Very often the child develops a seizure disorder. The children with CDD – Childhood Disintegrative Disorder are severely impaired and don’t recover their lost function.

The number of children affecting CDD is lesser than 2 children per 100,000 children with Autism Spectrum Disorder. Boys are more commonly affected by CDD than girls.

Causes of ASD

There are several theories about the cause or causes of ASD. Researchers are exploring various explanations but, to date, no definitive answers or specific causes have been linked scientifically to the onset of ASD. Research suggests that individuals with ASD experience biological or neurological differences in the brain.

In many families, there appears to be a pattern of ASD-related disabilities, which suggests that ASD is an inherited genetic disorder. Current research studies show that certain classes of genes may be involved or work in combination to cause ASD. There appear to be many different forms of genetic susceptibility but, to date, no single gene has been directly related to ASD.

1.2 Assessment, teaching and curriculum for children and Adolescents with autism

Assessment

There are many tools to assess ASD in young children, but no single tool should be used as the basis for diagnosis. Diagnostic tools usually rely on two main sources of information—parents’ or caregivers’ descriptions of their child’s development and a professional’s observation of the child’s behavior.

In some cases, the primary care provider might choose to refer the child and family to a specialist for further assessment and diagnosis. Such specialists include neuro-developmental pediatricians, developmental-behavioral pediatricians, child neurologists, geneticists, and early intervention programs that provide assessment services.

Selected examples of diagnostic tools:

·         Autism Diagnosis Interview – Revised (ADI-R)external icon
A clinical diagnostic instrument for assessing autism in children and adults. The instrument focuses on behavior in three main areas: reciprocal social interaction; communication and language; and restricted and repetitive, stereotyped interests and behaviors. The ADI-R is appropriate for children and adults with mental ages about 18 months and above.

·         Autism Diagnostic Observation Schedule – Genericexternal icon (ADOS-G)
A semi-structured, standardized assessment of social interaction, communication, play, and imaginative use of materials for individuals suspected of having ASD. The observational schedule consists of four 30-minute modules, each designed to be administered to different individuals according to their level of expressive language.

·         Childhood Autism Rating Scale (CARS)[9]
Brief assessment suitable for use with any child over 2 years of age. CARS includes items drawn from five prominent systems for diagnosing autism; each item covers a particular characteristic, ability, or behavior.

·         Gilliam Autism Rating Scale – Second Edition (GARS-2)external icon[10]
Assists teachers, parents, and clinicians in identifying and diagnosing autism in individuals ages 3 through 22. It also helps estimate the severity of the child’s disorder.

In addition to the tools above, the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition  (DSM-5) provides standardized criteria to help diagnose ASD.

Teaching Children with ASD

When selecting teaching strategies, we are all aware that ‘one size fits all’ does not apply. It is important to acknowledge the individuality of each child. But there is another aspect beyond this that must be kept in mind when teaching children with autism.

Autism is a population that takes a uniquely different developmental path. While each child has his own specific style, a large number of children with autism have certain unique commonalities. These, in addition to their uneven patterns of strengths and weaknesses, are some unique learning characteristics that must be considered for their educational implications.

Generalisation: The ability to apply a skill in different situations is known as generalisation. Opportunities to generalise a skill learnt across situations, time and people must be given.

Concrete to abstract: Due to difficulties with imagination children with autism may find understanding of abstract concepts difficult. Because they focus concretely they often have difficulty with remembering the precise order of tasks. Here again visuals help. In addition, while teaching always starts with concrete objects and then moves to abstract concepts. Learning needs to be experiential and related to real life situations.

Rote learners: Children with autism have excellent rote memory and they may use this to compensate for their difficulties in comprehension. It is therefore imperative to work on language skills.

Literal understanding: As children with autism are literal interpreters it is essential to be clear and concrete in communication. It is best to avoid irony, sarcasm and metaphors. Children with autism may have difficulty with shared attention tasks which involves understanding what another person may be thinking. This is a skill which is vital in any teaching situation and highlights one of the main areas of learning difficulty in people with autism.

Curriculum

Reading: Many students with ASD have strong visual skills and are often more successful in learning to read through a whole word sight recognition approach than through a more traditional phonics program. Whole words that are meaningful are usually easier for students to learn to read than words for which students have no basis of experience or knowledge. In the beginning stages of learning to read, it is critical to enable students to develop a sense of confidence.

While knowing the alphabet and knowing the sound symbol associations are usually regarded as prerequisite skills for learning to read, many students with ASD often have difficulty acquiring these prerequisite skills. Some students are able to recite alphabet letters and letter sounds by rote, but may be unable to apply this to decoding words in a fluent manner. The rate of reading fluency will affect a student’s ability to comprehend the message of the words. If a student needs to give more cognitive attention to a difficult decoding process, then it is likely that the student’s understanding of what the words are saying will decrease.

Some students may be better able to understand and learn the phonetic components of words after they have learned to read them through a whole word sight recognition approach, working backwards within a top-down framework from the whole to the parts. It is important to consider that, although some students may be unable to manipulate the symbolic representations of sounds, they may still be able to recognize and comprehend words and acquire skills in phonics.

As the student acquires more words, it is essential to provide activities in which these words are used in meaningful contexts. Ongoing practice in sentence construction enables the student to understand how words are organized to express thoughts and needs, as well as how pronouns, articles, and prepositions are used in context. Daily practice in sentence construction provides students with the opportunity to develop an understanding of grammar and to learn a framework for using language. This practice also reinforces that repetition and rehearsal of language construction are ongoing expectations of daily task performance.

Writing: While some students with ASD are proficient in printing and handwriting, many others have difficulty with written tasks because of difficulties with fine motor skills. The visual-motor coordination and fine motor movements that are required in written activities may be extremely frustrating and divert the student’s attention from the content of what he is writing to the physical process of print production. Difficulties with handwriting have been identified as one of the most significant barriers to academic participation for students with ASD in schools today.

There are many ways in which technology can be used to enhance and compensate for the limitations that students have in their writing skills. If fine motor skills are a barrier to participation and academic function, then seek the alternative of assistive technology.

The use of keyboards, word processors, and writing software has facilitated the writing process for many students with ASD. Learning to use a keyboard is a valuable skill for students to acquire. For many students with ASD, using a computer is a highly preferred activity. Teach and encourage the student to learn to use the keyboard as a writing instrument. This is a reasonable accommodation to the motor planning difficulties often associated with ASD. While learning to print can be a useful exercise for many, when students’ difficulties with penmanship inhibit their ability to demonstrate their knowledge and spark behavioural upsets, the use of the keyboard is a viable alternative.

In many cases, OTs are involved with students with ASD and provide assessments and information on a student’s fine motor and writing skills. OTs can provide recommendations about the strategies, resources, and accommodations that will be appropriate to assist students with fine motor and writing difficulties. As with other skills, it is essential to focus on the students’ strengths and determine the skills and methods that will be most functional for the students in the future.

Mathematics For many students with ASD, participation in mathematics can be a challenging aspect of the academic curriculum. There are several reasons for this:

•      Although many mathematical concepts can be demonstrated through visual examples, they are often accompanied by sophisticated verbal instruction.

•      The language of mathematics instruction has its own vocabulary, and the precision of instruction and usage of terms can vary from one instructor to another.

•      Mathematical terminology can be very complex and is challenging for students who struggle with processing the language of everyday interactions.

•      Along with the verbal, orthographic, and representational expressions of number, there is also the symbolic representation in the form of numerals.

•      Mathematical operations are usually performed with a pencil. Many students with ASD have fine motor difficulties and learning to form numerals and manipulate them on paper may be challenging.

1.3 Structured Teaching techniques

Structured Teaching is a set of teaching techniques developed by Division TEACCH (Training and Education of Autistic and related Communication-handicapped Children), a state-wide program serving individuals with autism spectrum disorders (ASD) in North Carolina.

Division TEACCH is a comprehensive treatment model that serves individuals with autism across the lifespan. Along with the structured teaching strategies, the model emphasizes an extensive understanding of autism, partnering with families, individualized assessment when developing and implementing strategies, and the development of skills across curriculum areas (with attention to the development of communication and social skills).

Structured teaching strategies can be implemented across settings and across curriculum area, as they serve as a vehicle to teach skills, and/or as a framework for a classroom setting.

These teaching strategies are based on an understanding of how autism impacts the thinking, learning, and behavior of an individual with ASD. Differences in auditory processing, imitation, motivation, and organization can hinder the educational success of students with ASD, as most traditional teaching strategies rely heavily on verbal instructions, demonstration, social reinforcement, and sequencing chunks of information or directives.

Structured Teaching strategies, however, capitalize on the strengths of students with ASD. These include providing predictable and meaningful routines through the use of structure, adding visual/structural supports to classroom instruction and activities to increase engagement and independence, and clearly organizing classroom spaces and teaching materials to reduce anxiety and increase appropriate behavior.

There are five elements of Structured Teaching that build on one another, and all emphasize the importance of predictability and flexible routines in the classroom setting. Division TEACCH developed a visual to illustrate the Structured Teaching components — the Structured Teaching pyramid:

Physical structure in the school setting

Physical structure is the foundation of structured teaching and is helpful in ensuring that learning is occurring in the classroom.

Visual schedules in the school setting

A visual schedule communicates the sequence of upcoming activities or events through the use of objects, photographs, icons, words, or a combination of tangible supports.

Work systems in the school setting

A work system is an organizational system that gives a student with ASD information about what is expected when he/she arrives at a classroom location.

Visual structure in the school setting

Visual structure adds a physical or visual component to tasks to assist students in understanding HOW an activity should be completed. 

1.4 Skill training and Communication skills

Provisions to meet the educational needs of individuals with autism are geared to enabling them to lead as independent a life as possible in adulthood. This implies that education would provide the individuals with work skills that would make them eligible for seeking employment, obtain employment, retain their jobs, be able to live independently, and have adequate leisure skills. Yet the few educational opportunities that currently exist are more focused on the development of cognitive skills and on ‘academics’ and pay little attention to the needs of individuals for when they become adults with autism. This near-absence of appropriate educational opportunities severely limits the possibility for employment—and therefore, the opportunities for independent living— for the vast majority of individuals with autism. In order to maximize the options for adults with autism to be independent as adults, current services and planning must also take into consideration the need for training in vocational skills, job opportunities, living options, and recreational opportunities.

Communication Skills

Using language and communicating with other people can be a challenge for many children with autism spectrum disorder (ASD). But with help and understanding, these children can develop communication skills.

In order to provide the best, most targeted communication treatment program for a child with autism, a comprehensive communication evaluation needs to be conducted by a speech-language pathologist (SLP). This assessment needs to evaluate pragmatic language skills (functional and social communication) as well as semantic language skills (the meaning of language­—including content and context). Because of the unique nature of autism, the assessment requires a team effort, involving family, teachers, and others who know the child well, and it should include more than standardized testing. A complete picture of the child is needed to make treatment decisions and to provide a baseline by which progress can be measured.

That’s where functional communication training (FCT) comes in. FCT involves teaching an individual a reliable way of conveying information with language, signs, and/or images to achieve a desired end. It’s called “functional” because it doesn’t just teach kids to label an item (ie associating the word RED to a picture of an apple) but focuses on using words or signs to get something needed or desired — a food, a toy, an activity, a trip to the bathroom, a break from something.

FCT involves the use of positive reinforcement to teach children about language and communication, to increase their ability to interact effectively with others to get their needs met.

Vocational Training

Training in work skills among young adults and adults with autism needs to focus on their strengths. In general, individuals with autism perform best at jobs which are structured and involve a degree of repetition. They thrive in an environment that is structured and well organized. Persons with autism often excel in tasks involving numbers, book keeping, data input, accounting, and tasks involving rote memory. In a job setting, they may have a good eye for detail and meticulous application of routine tasks. Given the social deficits of autism, they are best at jobs that do not involve a lot of dealing with the public, do not rely too heavily on social skills, and jobs which are routine and predictable. Most persons with autism will do happily and well on a repetitive type of job, such as putting a shuttle through a simple loom repetitively to weave long swatches of fabric, or silk screen printing. These are tasks that the non-autistic may balk at. They are also good at jobs where they might have to speak a lot, but can speak without interruption about their own interests. Training in vocational skills and employment for individuals with autism should thus focus on these strengths.

Some of the difficulties they face are with interpreting verbal and non-verbal communication, such as idiomatic language, facial expressions and body language, difficulties in jobs that require dynamic social interactions. Initiating and maintaining conversations on general topics may not be of particular interest to them. Similarly, jobs that require them to look beyond their narrow interests towards abstract ways may be difficult. Vocational training must teach skills to get a job, but more importantly, also directly teach the skills that are needed to keep those jobs.

Currently Action For Autism has a work skills training unit and that too is at a nascent stage. A few individuals have gone into the work arena, but finding open employment for most remains a difficult task.

Recreation and Social Life: Opportunities and Issues

Individuals who have autism, generally have to be taught to develop leisure skills, something that most of us do naturally. However, once taught, they may develop diverse leisure interests and often enjoy the same recreational activities as their non handicapped peers. A large number enjoy music and many are great singers, working on puzzles, computer games and physical activities that can be done on their own yet alongside others such as swimming, hiking, camping, cycling, and roller skating. Because of their socially awkward ways they are often made to feel unwelcome at sports facilities, except where the parents are able to surmount such hurdles. However, there are other public areas that people with autism visit. Increasingly one finds people with autism enjoying meals in restaurants and tolerating long hours in theatres and to enjoy the experience.

 

1.5 Behavioural Problems, Intervention.

Problem Behaviours — like all behavior — serves a function, usually one of these:

Your child’s difficult behaviour might also have specific triggers, like the following.

·        Routines and rituals
Children with ASD often like predictable environments, and they can get very upset if their familiar routines are broken. For example, your child might be upset if you change the route you usually take home from school.

·        Transitions
Your child might not understand it’s time to move on from one activity to another. Or like typically developing children, your child just might not want to.

·        Sensory sensitivities
Children with ASD often have sensory sensitivities and might like feeling or touching particular surfaces or objects. Your child might get upset if they aren’t allowed to touch.

·        Sensory overload
Your child might get upset if too much is happening around them, if they find a particular noise overwhelming, or if the light is too bright.

·        Unrealistic expectations
Like all children, your child with ASD can get frustrated if they’re expected to do something they don’t have the skills for, like getting dressed independently.

·        Tiredness
Children with ASD can have sleep problems. If your child isn’t getting enough good-quality sleep, this can cause difficult daytime behaviour.

·        Discomfort
This could include things like the feeling of clothes against skin, a prickly label, wet pants, a bump or pain. Check with your GP if you suspect there could be a medical condition causing your child’s behaviour.

·        Other conditions
Your child might have other conditions as well as ASD, like epilepsy, mood disorder or ADHD. These can all cause difficult behaviour. A medical assessment will help you to identify and manage these conditions.

Behavioral interventions are now considered an “established” treatment for ASD children, although they should not be expected to lead to normal functioning. They may improve the core symptoms of ASD, mainly in the first 12 months of treatment. Behavioral interventions are those in which instrumental learning techniques constitute the predominant feature of the intervention approach, based on the principles of behavior modification.

Ivar Lovaas and colleagues pioneered one of these intensive behavioral interventions, Applied Behavioral Analysis (ABA) in the 1960s. It seeks to reinforce desirable behaviors and decrease undesirable behaviors, teaching new skills and generalizing them through repeated reward-based trials. It requires a low student-to-therapist ratio and very intensive intervention (at least 25 hours a week). At this time, this is the only evidence-based approach to intensive early intervention for children with autism.

Discrete trial training (DTT), originally developed by Ivar Lovaas, is the most structured form of intensive therapy. It consists of breaking down skills into more discrete components to be taught in a stepwise fashion: the therapist presents an instruction (stimulus), prompts a response, waits for the child’s response, and provides an appropriate consequence depending on the response. The original behavioral interventions, based almost exclusively on DTT techniques, were developed at the University of California, Los Angeles under the Young Autism Project, and although they have demonstrated benefits in attention, imitation, obedience and discrimination, they have been criticized because of the lack of generalization and because the structured setting does not represent more naturalistic interactions between adults and children.

For this reason, contemporary ABA programs have been developed, which are taught in more naturalistic settings, with methods like Pivotal Response Training (PRT), the Natural Language Teaching Paradigm  or Incidental Teaching, where the child initiates the interaction, improving the generalization of the skills. In the current literature, the term Early Intensive Behavioral Interventions (EIBI) has arisen to summarize all these approaches, and it is accepted that they promote changes in the intelligence quotient and positive changes in adaptive skills and expressive and receptive language skills. New trends in the Contemporary ABA techniques include Positive Behavioral Support, Functional Assessment  and Functional Communication Training, with its “errorless” teaching.