Lecture # 104:
Autism, Introduction

copyright 2008 Cheryl K. Hosken, BSN, MS Psych.

Objectives for this lecture:

  1. Students will be able to describe the symptoms of Autism and Asperger's Syndrome.
  2. Students will know the changes of the brain that are found in Autism.
  3. The student will understand the three problems that require treatment in autism spectrum disorder.
  4. The student will understand the three types of treatment for autism.

Examples of Asperger's Syndrome and Autism
Asperger's Syndrome
Tommy Bartlett is a blue-eyed fifth grader who lives with his parents, twin brothers, two cats and a turtle. He is an honor-roll student who likes math and science and video games. An expert on toys that transform from cars or trains, he loves to turn them into robots or figures of people.

That is sometimes a problem. His fascination with the transformer toys was so strong that when they were not with him, he would pretend to be those toys, transforming from a truck into a robot. He would do this in a store, on the playground or in the classroom. His teachers thought this pantomime was delightful, but disturbing.

Then there were worrisome signs. Even though Tommy was fluent in speech, he did not seem to grasp that conversation had reciprocal rules - talking back and forth to one another. He also avoided looking into peoples' eyes. And although he was smart - he read by the age of 4 - he was fidgety and unfocused. He could not participate in group reading in his kindergarten.

When Tommy turned 8 years old, his parents finally learned what was wrong. Their bright boy had a mild form of autism call Asperger's syndrome. These children often respond well to therapy, but Tommy's parents were devastated. That is because just two years earlier, they learned that their twin sons were profoundly autistic. Seemingly normal at birth, the twins learned to say a few words before they went into their own secret world. They lost the abilities they had just started to gain at about 15 months of age. Instead of playing with toys, they broke them: instead of speaking, they emitted an eerie, high-pitched sound.

Meditate Word By Word On These Verses:
Luke 18:15-16.

Autism
Patrick Dow starts his day by reading the newspaper at the breakfast table. That is, his father reads it out loud to Patrick. He doesn't read it word for word but enough to tell Patrick what is going on in the world. After breakfast, his parents help him with the bathroom routine. On the right side of the sink, he has a basket with toothbrush, washcloth, hairbrush and all the other things he is going to need. On the left is an empty basket. He knows he is finished when each item moves from the right basket to the left basket. Structure and routine are essential. Just before he leaves for school, he picks up his favorite possession, a plastic bowl that the family calls Yellow. He lays Yellow at the foot of his bed and goes off to school.

Patrick's first responsibility at school is to present his journal for home-to-school communication to his teacher. Because he needs a routine, he has two half-day picture schedules that tell him what to do each morning and afternoon. His day begins with a group session that talks about the calendar and dates. Then he goes to the different learning areas in his classroom for three more sessions. Then there is a snack break and literature class with one of the regular classes in the school and a physical education session.

The afternoon session is similar to the morning. He has work sessions in his class and then goes to a computer class or the library where he helps to return books to the shelves. On Fridays, he learns community skills. He goes bowling with the regular class children, to the barber, buys items for a project in his class and then returns to school.

Patrick and his traveling companion, Bill walk home from school together every day. Bill helps him learn to walk home. When he gets there, he goes to Yellow and holds the bowl tightly against himself. In the evenings, he listens to music, eats dinner with his family, staying close to them. There is a schedule that is posted on the wall at home. If his schedule changes, his mother changes the pictures so he knows what is happening.

He often goes to bed at 10 P.M., but he may sleep only 2-3 hours. It is not unusual for him to get up at 12 midnight and stay up the rest of the night. In his room is a small light bulb that is turned on and means that he should stay in his room and not walk around the house. Here it is safe and comfortable so he can be up and around. Patrick needs care - every hour of the day.

Definition of Autism
In the past few years in the West, the incidence of autism has increased from what was thought to be 1 in 10,000 children suffering with the syndrome to perhaps as 1 in 150 children with the syndrome. The problem is now 5 times as common as Down's Syndrome. Parents are seeking help in offices of psychologists, schools are adding more personnel to help teachers in the classroom, and research institutions are trying to find the cause for the disability that has such a wide range of problems.

Scientists in France, Great Britain, Italy, and the United States are working together to examine the causes for the disease. They examine environmental factors, genetic factors, and use advanced brain-imaging technology to probe the minds of children with autism.

Autism is a developmental disability significantly affecting verbal and non-verbal communication and social interaction, generally evident before the age of three. It adversely affects educational performance. Other characteristics associated with autism are repetitive activities and inappropriate movements such as waving fingers in front of face, resistance to environmental change or changes in daily routines and unusual responses to sensory experiences.

Question:
1. The cause of autism is:
(Select the best answer.)
a. an imbalance of neurotransmitters.
b. unknown.
c. due to some developmental delays.

 

 

Descriptive Characteristics of Autism
Language Development
Persons with autism have a broad range of language abilities from nonverbal communication to quite complex types of communication. The two most common types of problems are delayed language and echolalia. There is delayed language in about 50% of the people with autism. They may repeat syllables such as lo-lo-lo or da-da-da. Sometimes there is a change in the way these are said and those people around them realize he/she is trying to indicate some communication. These people may never learn speech and language skills. They need the help of other systems to communicate. There is sign language, computer assisted communication, and pictorial communication boards.

Echolalia is the echoing of other peoples' language by constantly repeating a portion of what is heard. This happens to most young children as they are beginning to talk, but usually disappears around the age of three. People with autism may have this symptom for all of their lives. Some researchers think this language is meaningless, but others think it is the autistic person's way of filling in the conversation gaps because he/she cannot talk back like other people can.

Social Interaction
A lack of social interaction is the hallmark sign of a person with autism. They spend a large portion of time alone, do not form good contact with parents, need to learn eye contact with others, develop strong contacts to particular objects, and don't seek comfort from others when they are hurt or upset. It is an enormous task for the autistic child to express feelings in a socially acceptable way. If their environment is structured, that is, everything is in the same place all of the time and they know where they are to go and how to get there, it is easier for them to be social.

Need for environmental predictability
Structure is the source of security for the autistic child. If there is a change of schools, celebration of holidays, people with autism experience a high degree of anxiety. The way things are arranged in the living room or the bathroom have great significance for the autistic child. The picture schedule that Patrick uses is so helpful in making him be comfortable at home and school.

Unusual Responsiveness to Sensory Stimulation
Many such children have an under- or over responsiveness to sensory stimuli from an early age. One mother said that her autistic son hated having a bath and getting dressed. He screamed when someone picked him up. Touching him actually seemed to cause him pain.

For most of us, the integration of our senses helps us to understand what we are experiencing. For example, our senses of touch, smell and taste work together in the experience of eating a ripe peach: the feel of the peach fuzz as we pick it up, its sweet smell as we bring it to our mouth, and the juices running down our face as we take a bite. For children with autism, sensory integration problems are common. Their senses may be over-or under-active. The fuzz on the peach may actually be experienced as painful; the smell may make the child gag. Some children with autism are particularly sensitive to sound, finding even the most ordinary daily noises painful. Many professionals feel that some of the typical autism behaviors are actually a result of sensory integration difficulties.

Match these terms with the definitions below:
A. stereotypical behavior, - B. echolalia, - C. structure, - D. sensory stimulation.

2-1. repeating parts of sentences that are heard.
A, B, C, D.

2-2. a piece of clothing that feels like sandpaper on the skin.
A, B, C, D.

2-3. waving of the hands in front of the face.
A, B, C, D.

2-4. a feeling that everything is in its place and predictable.
A, B, C, D.

 

 

Intellectual Functioning
Autism occurs in children of all levels of intelligence, ranging from those who are gifted to those who appear to be profoundly retarded. Although data from different studies varies, about 60% of autistic children have intelligence quotients below 50, 20% have intelligence quotients of 50-70, and 20% have intelligence quotients of above 70.

Higher function autistic disorder refers to a condition in which the child has an intelligence quotient of above 70. Those people with higher thought processes can pursue a fairly wide range of academic endeavors. These people develop speech, but they may continue to have sensory sensitivity and social adjustment problems.

Persons with autism may also exhibit some of the following traits that occur at about 15-18 months of age.

There are many myths and misconceptions about autism. Contrary to popular belief, many autistic children do make eye contact; it just may be less or different from a non-autistic child. Many children with autism can develop good functional language and others can develop some type of communication skills, such as sign language or use of pictures. Children do not "outgrow" autism but symptoms may lessen as the child develops and receives treatment.

Question:
3. The child with autism:
(One or more of the following answers may be correct.)
a) displays symptoms at about the age of 15-18 months.
b) has normal feelings.
c) plays alone.
d) responds to his parents when he sees them.

 

 

Descriptive Characteristics of Asperger's Syndrome
Asperger's Syndrome (AS) is a neurobiological disorder named for a Viennese physcian, Hans Asperger, who described the pattern of behaviors in several young boys who had normal intelligence and language development. However, they also had some autistic-like behaviors and marked deficiencies in social and communication skills. Although the syndrome was described in 1944, it was not until 1994 that it was added to a formal list of psycho-biological disorders.

Persons with AS can exhibit a variety of characteristics and the disorder can range from mild to severe. Persons with AS have marked deficiencies in social skills, prefer sameness of environment, and have difficulties with making changes in their lives. They may have obsessive routines and may be preoccupied with a particular subject of interest. They have a great deal of difficulty reading nonverbal cues (body language, facial expressions). The person with AS may prefer soft clothing, certain foods, and he may be bothered by sounds or lights no one seems to hear or see. He is overly sensitive to sounds, tastes, smells and sights. The person with AS perceives the world very differently. Therefore, many behaviors that seem odd or unusual are due to those neurological differences. He is not trying to be rude or exhibit bad behavior. His problems are not due to improper parenting.

By definition, those with AS have a normal IQ and many of them exhibit exceptional skill or talent in a specific area. Because they have the ability to function in society, those with AS are viewed as eccentric or odd. They are naive and may be subject to teasing and bullying from others. While their language development seems normal, they often have trouble with pragmatics. Their vocabularies may be extraordinarily rich and some of them sound like "little professors". They have difficulty using language in a social situation even though they would like to talk and be close to others. They are able to learn social skills in much the same way that normal persons learn to play the piano - by repetition, demonstration, and practice with others.

There is a great deal of debate about how to classify AS. It is presently described as an autisitic-related disorder. Some professionals think that AS is High Functioning Autism and others think of it as a Nonverbal Learning Disability. Because it was virtually unknown years ago, many children either received an incorrect diagnosis or remained undiagnosed.

Persons with Asperger's Syndrome usually display the following signs and are usually diagnosed by the age of 6:

Question:
4. Asperger's Syndrome is different from Autism because:
(One or more of the following answers may be correct.)
a) the symptoms occur in an older child.
b) they can focus on a subject and know much about it.
c) such children have difficulty communicating.

 

 

Causes of Asperger's Syndrome and Autism
Basically, we do not know what causes these communication disorders. As mentioned above, researchers are working as fast as they can to find the reason why the brain does not work normally. They believe that Asperger's and autism are two types of a complicated and variable disorder. They also understand that severe autism is sometimes accompanied by high intellect that compensates for the syndrome. But most often autism is characterized by mental retardation and many deficits.

The most thought provoking finding is that the components of autism, more than autism itself, tend to be familial characteristics. Even though autistic people rarely have children, often a close relative is affected by a certain aspect of autism. For example, a sister might have odd, repetitive behavior or be excessively shy. A brother may have difficulties with language or very limited social contacts.

As with many diseases, researchers look for genetic sources of the problem. There are an estimated 20 genes that may be linked to autism. The most prominent genes for study are those that regulate the action of three powerful neurotransmitters: 1) glutamate, which is involved in learning and memory, 2) serotonin and 3) gammaaminobuturic acid that have connection to obsessive-compulsive behavior, anxiety, and depression. Other genes that control brain development, cholesterol, and the immune system may be part of why the brains of autistic people are different.

There is clearly a difference in how the mind works. Most children by the age of four years understand that other people have thoughts, wishes, and desires, which are not the same as their own. Children with autistic disorders appear to think that whatever is in their mind is also in the mind of others around them. The idea that other people - teachers, parents, siblings - may have another view of things, have concealed motives, or deceiving thoughts does not occur to an autistic child. These children don't readily tell lies because they just don't think in that way.

Question:
5. Scientists think that autism and Asperger's syndrome are caused by:

 

 

Some scientists think this problem is related to the inability of autistic children to imitate their parents. If an adult pounds two blocks on the floor, usually an 18-month-old child will do the same. But the autistic child does not. Consequences for this failure are serious. In the early years of life, imitation is one of the child's most powerful tools for learning to develop neuron connections in the brain. It is through imitation that a child mouths his first words and masters language of body posture and facial expression. Most autistic people cannot read the outward signs of what is happening internally in another person. Understanding non-verbal communication comes only after a long struggle and even then they may fail to detect the subtle signals that a person gives about his internal thoughts.

In study after study, it has been found that autistic people do not process information as others do. Brain activity in the prefrontal and parietal cortex of the brain is far below normal. When adult autistic people are asked to perform a task involving spatial memory (where certain items are located and putting them in a certain order), they have much difficulty. These two areas of the brain are essential to planning and problem solving. They also keep in memory where objects move in space and if there are changes. This memory seems to fail in the autistic person. Other studies suggest that the key connections between parts of the brain are not made or do not function at an optimal level.

Misconnections in the Brains of Autistic People
Does autism start as a problem with the brain stem and then radiate out to affect other parts? Or perhaps it is a widespread problem that become more pronounced as the brain is supposed to set up the circuits we talked about in Lecture 1? There is ongoing dispute about when the brain begins to fail. One thing is very clear: very early, children with autism have brains that are anatomically different in microscopic and macroscopic detail.

In postmortem studies, it has been found that there are striking abnormalities in the limbic system, which includes the amygdala. This section of the brain is the primitive emotional center. The hippocampus, a seahorse structure critical to memory located near the amygdala, is also affected. The cells of both of these centers are small and immature compared to cells of a normal brain.

In the cerebellum of autistic persons, the Purkinje cells which integrate sensory data coming from outside the body, are fewer in number than normal. Without these cells, the cerebellum is unable to do its job. Normally, the cerebellum receives torrents of information about the outside world, computes their meaning, and prepares other areas of the brain to respond appropriately.

In studies, it has been found that the brain of the autistic child is normal at birth, but by the time the children are 2-3 years of age, their brains are much larger than normal. This abnormal growth is not uniformly distributed. Scientists know that the gray matter of the cerebral cortex and the white matter that contains the fibrous connections between parts of the brain grow too quickly. Scientists think that this abnormal growth may kill the Purkinje cells. The question is why this happens. Perhaps it is a otherwise normal process that switches on too early or shuts off too late. That process is controlled by genetic activity.

Question:
6. The brain of an autistic child has abnormalities in: (3 areas)

 

 

There are genes that control four brain-growth regulators that have been found in newborns who may developmental retardation or autism. One of these is called vasoactive intestinal peptide. Its role is to help development of the brain, the immune system, and the gastro-intestinal tract as well. In autistic children, there are often intestinal problems and allergies to wheat and rye glutin.

If there are indeed certain biological markers for autism, perhaps those infants who have them could be identified. As they grow, it might become possible to monitor their neurological changes and intervene when something begins to go wrong with the brain. Right now we only study what happens after autism occurs. There are a bewildering number of things these children cannot do. What we need to know is how this all happened.

Drugs taken by pregnant women are also being studied. We know there are certain substances that cause birth defects. They are called teratogens. Scientists are now studying teratogens' impact on a gene called HOXA1. This gene switches on very briefly in the first trimester of pregnancy and is silent ever after. In experiments with mice, if this HOXA1 gene is destroyed, their brainstems are missing an entire layer of needed cells.

When the causes for autism are found, it is likely that there will be multiple routes for the cause of autism - genetic and non-genetic. There will be new ideas for correcting or preventing autism. It is hoped that in a decade from now, there will be drugs that combat autism. It is said that genes give scientists a target to work toward. If they know the gene that causes this disability and how it works, they can design intervention of drugs to combat it.

The thing that is so terrible about these various autistic disorders is that they affect the very young. That also gives hope. Since neural connections of the brain are established through experience, well-targeted mental exercises can make a difference in the autistic brain. The question is why 25% of autistic children respond to such exercises and 75% of them do not. Is it because the 75% have irreversibly damaged brains or is it because the proper therapy has not been found? May God bless the efforts of those who are trying to find a cure for this syndrome.

Question:
7. What does the term "autism" mean to you?

 

 

Because autism is a spectrum disorder, no one method alone is usually effective in treating autism. However, professionals and families have found that a combination of treatments may be effective in treating symptoms and behaviors that make it hard for individuals with autism to function. These may include psychosocial and pharmacological interventions.

The child with autism has three major problems:

In social interaction, the child may have difficulty understanding praise, tone of voice (used with a variety of emotions), and types of touch. In addition, there is a lack of interaction and the building of relationships with parents, family, and peers. They may physically attack someone without provocation. Other behaviors such as hand-flapping, rocking, or obsessive placing objects in order, and head banging on a wall are very disturbing to other people and family.

The second problem of communication may be large or of little importance. There are autistic children who can be taught speech, and others who cannot speak. Also, the child may have difficulty in comprehending natural gestures that are used in communication - facial expression, nodding, pointing, and other hand gestures. If he hears spoken word, he may not be able to process the thoughts that are conveyed. If he is unable to use language to communicate his needs, the child may resort to screaming.

The third problem is processing stimuli that come from his environment. His brain needs to sort and direct action when he receives a stimulus. The child may demonstrate over selectivity - when he focuses on one part of an object instead of the whole. An example of this is that if we read a book to a child, he focuses not on the words, but on the turning of pages. A child with autism may also have difficulty with modulating senses. He may react with hypersensitivity or hypo-sensitivity to auditory, tactile, muscular, or vestibular stimuli. For example, a child may never respond to loud noises, or he may scream and cry uncontrollably from them. He may respond to different types of fabric as if they irritate him, оn the other hand, he may not respond when he cuts his finger or burns himself on a hot stove.

Question:
8. Why are the three problems associated with autism so difficult to treat?
(Only one of the following answers is correct.)
a) because the problems are due to receiving and giving back all types of information.
b) because the child cannot talk.
c) because his behavior is not regulated.

 

 

Treatment of the Autistic Child
Many treatment approaches have been developed to address the range of social, language, sensory, and behavioral difficulties. These include Applied Behavioral Analysis (ABA) with Discrete Trial Training (discrete trials); TEACCH; PECS; Floor Time; and Social Stories, and Sensory Integration.

Applied Behavior Analysis - ABA
Many of the interventions used to treat children with autism are based on the theory of applied behavior analysis (ABA). This means that if certain behavior is rewarded, it is likely to be repeated. The behavior that is not wanted - hand-flapping, rocking, etc. is not rewarded and therefore is decreased or stopped. Although ABA is a theory, many people use the term to describe a specific treatment approach with subsets that include discrete trial training or Lovaas. While the terms discrete trial and Lovaas have been used interchangeably, only practitioners who are affiliated with Lovaas can be said to implement "Lovaas Therapy."

In discrete trial training, every task given to the child consists of a request to perform a specific action, a response from the child, and a reaction from the therapist. It is not just about correcting behaviors but is designed to teach skills, from basic ones such as sleeping and dressing to more involved ones such as social interaction. Discrete trial training is an intensive approach. Children usually work for 30 to 40 hours a week one-on-one with a trained professional. The child is not taken from his home, the therapist comes to him. Tasks are broken down into short simple pieces, or trials. When a task has been successfully completed, a reward is offered, reinforcing the behavior or task.

For example, one of the first tasks that an autistic child must learn is to sit for a time. He may not want to do this and screams when asked to sit. He may also not even respond to the request to sit. However, he is carried to a chair and put on it. When he sits for 10 seconds, he is rewarded with one of his favorite foods or activities. A friend from our church had an autistic son. When he started ABA, he was rewarded with a short time of jumping on a large soft pillow. Then he went back to sit on the chair for another short period of time. This therapy is very intensive. The child works with a therapist 8 hours per day. This is how the speech skills, social behavior, and adaptive skills are taught.

This method is not without controversy. Some practitioners feel it is emotionally too difficult for a child with autism, that the time requirement of 30 to 40 hours a week is too intensive and intrusive on family lifeб and that while it may change a particular behavior, it does not prepare a child with autism to respond to new situations. However, research has shown that ABA techniques show consistent results in teaching new skills and behaviors to children with autism.

Question:
9. Applied Behavior Analysis is:
(Select the best answer.)
a) very hard to do.
b) a system of rewards for appropriate behavior.
c) learning small amounts of information at a time.

 

 

There are many "challenges to learning" encountered by children with autism. Below are some of the individual challenges and how ABA specifically addresses those issues. Again, remember that this is an extremely basic description.

Low motivation - Reinforcers for autistic children tend to be on the idiosyncratic side, so the types of things used for other children in various behavior modification interventions probably will not work with these kids, at least at the beginning. You need to find what will work for this particular child to motivate his interest in completing a task. Every effort should be made to maximize the contrast between positive and negative consequences so that the concept of cause-and-effect can be learned.

Limited reinforcement repertoire - ABA principles recognize that social reinforcers (approval or disapproval) are usually not effective. Praise, in and of itself, is not enough at first, but can be paired with a more tangible reinforcer (such as a favorite toy or activity, etc.). Eventually the tangible reward can be taken away and the continuing smiles and words of praise "come to be effective in their own right."

Short attention span - ABA breaks each task into very small, measurable steps.

Easily distracted - Teaching in a quiet environment by reducing auditory and visual distractions is important. Noise level, movement of others, windows, even air conditioners can be excessively distracting to autistic children. The goal is to begin in a very structured environment, but to move the child into more and more ordinary environments as they become more successful "so that the child becomes able to work in the presence of distracters."

Learn more slowly - Repetition is an important method for autistic children, but it should not be boring or tedious. That is our responsibility - to make sure it's NOT TEDIOUS. Some kids require literally hundreds of trials on order to learn a specific concept, but they also will learn it more effectively if it is practiced within a short time span. In other words, a skill that is practiced once a day is not as effective, and could take months longer to master, than one practiced twenty times a day. In order to know when a child has really mastered a skill, it is rehearsed, and then the child is distracted with other tasks. Then, they go back to the first task and see "can they still do it?" It is not repetition for the sake of repetition; it is done in a manner to maximize learning.

Difficulty understanding abstract concepts - ABA therapists use concrete examples of concepts and begin with the simplest language that the child is able to understand. Then more complex language is added as the skills and concepts are learned. We definitely want to get the children to the point where they can understand everyday language - natural language.

Question:
10. Autistic children learn best in what type of environment?
(Select the best answer.)
a) at home, with little distraction, with repetition and reinforcement.
b) at school, with little distraction, with repetition and structured environment.
c) at home, with family, repetition, and structured enviroment.

 

 

Poor learning by observation - These children have difficulty picking things up incidentally, so the need is to explicitly and systematically teach each skill or behavior. ABA stresses the skill of imitating people because if they can imitate, they are able to learn a lot of skills that they would otherwise not.

Poor differentiation between relevant and irrelevant stimuli - These children often do not know the difference between the essential aspect of a situation and those aspects that are trivial. Focusing attention and presenting only the stimulus that is considered essential is a way of circumventing this problem. It is important to watch out for erroneous associations. An autistic child may learn to tell boy dolls from girl dolls based on the shoes that they wear rather than the more obvious differences. These associations may not be reliable and we have to teach him to focus on the relevant aspects of the situation. Be careful with tools like flash cards, because you could find out that the child is discriminating one from another based on a bent corner or smudge on the cards. He stressed the need for using different materials and in different ways so that the answer the child gives is based on the concept you are trying to teach.

Behaviors such as self-stimulation interfere with learning - When they are self-stimulating (flapping hands, rocking, repeatedly hitting the table) that's often where their attention is focused. If 90% of their attention is invested in their self-stimulating activity, there's only 10% left to focus on the task at hand, so we work on suppressing those behaviors that interfere with learning.

Difficulty learning in large groups - Once the child is learning well in a one-to-one setting, he can begin moving to a 1:2 setting; 1:4; 1:8; etc. by gradually increasing the size of the environment as he is able to maintain attention and remain on the learning task.

Does not occupy self appropriately during free time - ABA provides structure to free time and teaches leisure skills. We build in play skills and other types of activities that they can do independently so that they're not going off into their autistic world.

Sensory/motor impairments - Sometimes their reactions can be over-responsive or under-responsive. Often the visual channel works better than the auditory for obtaining information. The children who are the most successful in ABA are children who are able to use the auditory channel successfully. Therapists attempt to balance playing to their strength by using the visual channel in teaching, with pushing the child to develop better use of their auditory system. For children who don't like touch, we touch them. There is a belief they will not only become able to tolerate it, but actually enjoying it.

Question:
11. Autistic children learn best through:
(Select the best answer.)
a) auditory stimulation.
b) focusing attention.
c) visual information.

 

 

Components of a Discrete Trial
Each skill is taught in very small and very brief units called "trials". Each trial consists of an instruction, a prompt, an opportunity/response, and feedback. The instruction is given in very clear language that the child can understand. As the child becomes able to handle more complex language, it moves toward a more natural language base. They may begin with a direct stimulus "look at me" then move to a more natural stimulus such as just saying the child's name to get his attention.

Prompts are not always needed, but a therapist will use something that will bring the desired response. These can be a visual prompt such as a gesture, or a physical prompt - taking the child's hand and moving it through the desired motions, but the goal is for a child to do the desired task with no prompt at all. The response should be evident within about 5 seconds. If there is no response, or an incorrect response, the trial is considered to be over and a new one begins (although it may be the same task - in fact, many people would not be able to tell where one "trial" ends and the next begins). It is broken up this way so that data can be obtained on the progress of the child.

The therapist gives feedback on each trial immediately. The more information that is provided to a child here, the faster the learning can take place. It is important, he says, not to praise every response; some will be terrific, some barely adequate, some not quite accurate and some simply unacceptable (such as throwing things). Use the feedback to indicate where the response falls. Some people think that merely saying 'no' to a child constitutes an aversive response to him. But hearing the word 'no' is a very common, everyday event. It is part of the world, part of life, and if the child cannot tolerate simply hearing the word 'no', he is going to have a really difficult time in life. It is important for us to teach children to be able to handle the word 'no' simply at an informational level. That doesn't imply that we scream at him, but firmness can be conveyed without disrupting the situation.

There are times to be very supportive even though they have given the wrong answer. They worked hard, they are sitting appropriately, they are careful about their response, but it is incorrect. Clear information is conveyed in the words and the vocal inflection "Oh, no. Good try." If they are not attentive, it's OK to say "No. You need to look at me."

The only way to tell if learning is actually taking place is if the child gives a response that he can only make if he understands. Evaluation of the effectiveness of trials is a critical part of the therapy. Data tells whether a student is making progress or not. If the child does not make progress, the therapist needs to look at his method and perhaps change it rather than concluding that his student doesn't learn well. Behavior therapists need data to demonstrate the cause-and-effect relationship between the intervention and the outcome.

The distinctive feature Applied Behavior Analysis program is intensity. It takes many, many hours a day, and is very directive and instructionally based. If a family is not comfortable with a directive-type program, they should find another program that would better suit their needs. The goal for children is to direct them because they are not able to direct themselves. There are many times a day when a parent is also quite directive with his children. Brushing their teeth is a good example. Children would rather not do that. But the parent's decision is based on good health for his child and he insists that it be done.

A lot of people think the ABA program is not sufficient because they believe that generalization does not occur, and if a child can't take information from one situation and use it in another then he's not really learning; he's just mimicking. Generalization is part of the ABA package and if the therapist understands and includes that in part of the work that he does, the result is generalization. Strong parental involvement in the ABA program is stressed as a very large component of its success.

Question:
12. It is alright to say "no" to an autistic child because:
(Only one of the following answers is correct.)
a) he needs to hear that word.
b) because it is a part of everyday life.
c) because his behavior is usually awful.

 

 

TEACCH

TEACCH (Treatment and Education of Autistic and Related Communication Handicapped Children) was developed at the School of Medicine at the University of North Carolina in the 1970s. It is a structured teaching approach based on the idea that the environment should be adapted to the child with autism, not the child to the environment. It uses no one specific technique, but rather is a program based around the child's functioning level. The child's learning abilities are assessed through the Psycho Educational Profile (PEP) and teaching strategies are designed to improve communication, social and coping skills. Rather than teach a specific skill or behavior, the TEACCH approach aims to provide the child with the skills to understand his or her world and other people's behaviors. For example, some children with autism scream when they are in pain. The TEACCH approach would search for the cause of the screaming and then teach the child how to signal pain through communication skills.

There have been criticisms that the TEACCH approach is too structured, that children with autism, particularly high-functioning individuals, become too focused on the charts, organizational aids, and schedules, and that it discourages mainstreaming. Others feel that, in an environment conducive to learning, ultimately the child with autism understands what is expected and how to respond.

Picture Exchange Communication Systems - PECS

One of the main areas affected by autism is the ability to communicate. Some children with autism will develop verbal language, while others may never talk. An augmented communication program, such as Picture Exchange Communication Systems (PECS), is helpful to get language started as well as to provide a way of communicating for those children that do not talk.

PECS was developed at the Delaware Autistic Program to help children and adults with autism to acquire functional communication skills. It uses ABA-based methods to teach children to exchange a picture for something he wants - an item or activity.

The advantage to PECS is that it is clear, intentional and initiated by the child. The child hands you a picture, and his or her request is immediately understood. It also makes it easy for the child with autism to communicate with anyone - all they have to do is accept the picture.

How to Begin Using Visual Supports

1. Decide what the visual supports need to do:

2. What does the child understand?

The child should not struggle to understand what the individual pictures mean. You do not write appointments in another language for yourself, therefore, do not use visual pictures that are hard for the child to understand. You may need to use a photograph instead of a picture symbol. Sometimes a picture is too abstract for these children. Sometimes using larger pictures helps a child understand more easily. Put the exact word on a picture that you use with your child. If you ask your child if he needs to use the toilet, write the word "toilet" - do not use another word.

3. Gather the labels, make picture symbols, or take photographs.

Don't take a picture of the whole living room if the object you want to show him is the television. Make sure that the photo is not blurry or too dark.

4. Make the photographs, labels or pictures durable.

5. Decide where to put the communication board.

There should also be a NO CHOICE card to use if an activity or food is unavailable to the child.

A daily schedule shows the major events of a child's day. Keep it simple. Start small and expand as needed. It is best to just include the major portions of the day. Otherwise the schedule might get too long and difficult for a child to follow successfully. This type of clear, simple support provided ahead of time can help a child predict what is going to happen in the future. It also helps them understand when there is a change in the routine so they can adapt and become more flexible.

Use it and encourage the child to participate. Now that you've made the schedule, it is important to use it consistently, making it part of the child's daily routine. The schedule should be used to preview what is going to happen throughout the child's day and referred back to during each transition. In order for the schedule to be useful it is important to have some way of indicating that an activity has ended. You can do this by either turning the picture over or placing it in the pocket. If your child wanders away from an activity, you can also use the schedule to guide the child back.

When you first begin using the schedule, you probably need to perform the steps yourself. This is called modeling. It allows the child to learn how to use the schedule by first watching you. However, as soon as possible the child needs to actively participate in the process. For example, at first you may need to put the schedule together yourself but soon the child might take part by placing each picture on the board as you hand it to them.

Question:
13. The picture system is good because:
(Select the best answer.)
a) it helps the child understand his schedule using visual cues.
b) it helps him communicate using visual cues.
c) it is part of a daily routine for autistic children.

 

 

Floor Time
An educational model developed by child psychiatrist Stanley Greenspan. Floor Time is much like play therapy in that it builds an increasing larger circle of interaction between a child and an adult in a developmentally-based sequence. Floor time means that a parent and/or a therapist spends time with a child on the floor, in play which is actually therapy. Greenspan has described six stages of emotional development that children meet to develop a foundation for more advanced learning - a developmental ladder that must be climbed one rung at a time. Children with autism may have trouble with this developmental ladder for a number of reasons, such as over- or under-reacting to senses, difficulty processing information, or difficulty in getting their body to do what they want. The emotional developmental stages are these:

  1. Regulation and Interest in the World - 3 months
  2. Formation of Relationships and Attachments - 5 months
  3. Intentional 2-Way communication - 9 months
  4. A Sense of Self and Behavioral Organization - 13 months to 18 months
  5. Emotional Ideas that are Understood and then Expressed - 24-30 months
  6. Emotional Thinking - 36 to 48 months

Floor time means that the parent and/or therapist actually sits on the floor with a child to help him interact with the environment. Usually, it is recommended that the child has two sessions per day of 3 hours. When this treatment begins, the parent looks for some reaction from the child. Often a child with autism plays in a mechanical way by lining his toys in a row or circles. What the parent tries to do is to help the child respond to him and not simply stay in his own world. For example, a parent with an autistic child may just sit with him when therapy begins. He may talk gently to him and attempts to have the child respond to his speech. This may be through a sign that the child is listening or through motor response of the child. What the parent hopes to accomplish is that the child will "close a circle" of communication - there will be a stimulus to the child, and he will respond.

Through the use of Floor Time, parents and educators can help the child move up the developmental ladder by following the child's lead and building on what the child does to encourage more interactions. Floor Time does not treat the child with autism in separate pieces for speech development or motor development but rather addresses the emotional development, in contrast to other approaches which tend to focus on cognitive development. It is frequently used for a child's daily playtime in conjunction with other methods such as ABA.

The goals of Floor Time intervention are to help the child become:

Question:
14. Floor time therapy has a different approach because:
(Select the best answer.)
a) it occurs on the floor where the child plays.
b) it is based on emotional needs of the child.
c) it is gentle.

 

 

This therapy can be very effective, but needs to be thoroughly understood by the parent and therapist. There are detailed instructions in Dr. Greenspan's textbooks and on his Website. However, we cannot review all the details in this lecture. This model of therapy has also been successful, and is often used with ABA therapy. The website containing this material is quite detailed and provides many good ideas about working with children. See http://www.coping.org/earlyin/floortm.htm

Match these terms with the definitions below:
A. Applied Behavioral Analysis - B. Discrete Trials - C. Floor Time - D. Picture Exchange

15-1. Use of cards to teach a child to communicate.
A, B, C, D.

15-2. Rewarding the child for appropiate behavior.
A, B, C, D.

15-3. Working with a child through play activities.
A, B, C, D.

15-4. Teaching one small part of an activity.
A, B, C, D.

 

 

Sources for this lecture:
Bonesteel, Nash, and Park, "The Secrets of Autism", TIME, May, 2002, pp.46-56
Websites: Autism Society of America
Online Asperger's Information and Support