Helping Children with Autistic Disorder
by Melissa Nishawala, M.D.

Introduction

Autism occurs in 1 in every 500 births, at a rate of 5 boys to every girl. Autism is the third most common developmental disability following mental retardation and cerebral palsy, and currently affects 400,000 people in the U.S.

According to statistics from the U.S. Department of Education and other governmental agencies, autism is growing at a startling rate of 10–17 percent per year. Whether this statistic represents a true increase in the number of children with autism or whether it is affected by increased surveillance and a broader definition of the disorder is not definitively known.

Autism (ASD) is considered a spectrum disorder and viewed as a continuum; at one end are high functioning children with Asperger Syndrome and at the other end are children who are more severely impaired. Youngsters can fall anywhere on this spectrum, but the problem they all have in common is difficulty with social and communication skills

What is Autistic Disorder?

Autistic disorder is characterized by impairments in three major areas:

1. Qualitative impairment in social interaction, manifest by at least two:
   • Marked impairment in use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
   • Failure to develop peer relationships appropriate to developmental level
   • Lack of spontaneous seeking to share enjoyment (e.g. lack of showing, bringing, or pointing out objects of interests to other people)
   • Lack of social or emotional reciprocity
   
   
2. Qualitative impairment in communication as manifest by at least one:
   
   • Delay, or total lack, of spoken language (not accompanied by an attempt to compensate through alternative mode of communication such as gestures or mime)
   • In individuals with adequate speech, marked impairment in 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 development level
   
   
3. Restricted, repetitive and stereotyped patterns of behavior, interests and activities, as shown by at least one:
   
   • Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that are abnormal in either intensity or focus
   • Apparently compulsive adherence to specific, nonfunctional routines or ritual
   • Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole body movements)
   • Persistent preoccupation with parts of objects

At what age can signs of Autistic Disorder first be observed?

Before 18 months, signs of autism can be present. Here are some red flags: The child

• Does not turn when called by 12 months
• Does not point by 15 months
• Has fewer than a dozen words by l8 months
• Does not enjoy interactive games, like peek-a-boo or looking at a book
• Makes few demands; talks or makes language-like sounds to self without need for partner
• Does not comprehend what is said to him/her

If concerned, parents should seek a comprehensive evaluation which includes referrals by their pediatrician to an audiologist, early intervention services and an autism specialist (child and adolescent psychiatrist, neurologist or developmental pediatrician).

What causes Autistic Disorder?

The general consensus is that Autism is a genetic disorder involving up to 20 or more genes which cause abnormalities in brain structures or functions. Environmental triggers such as a difficult birth, viruses, or toxins may play a role. There is no evidence to support vaccines as a cause. Neuroimaging, EEG, and other studies investigating the causes of Autism are currently underway.

How can children with Autistic Disorder be helped?

Most children with Autistic Disorder need a combination of treatments to make progress. No one treatment is equally effective in all children or for all features of the disorder. Children with this disorder can benefit from a range of treatments such as educational therapy, speech/language therapy, motor skills development, and play and socialization with peers depending on the needs of the individual child. Early, intensive, and structured education can help children grow and learn new skills such as talking and communicating, interactive play, learning, and caring for oneself. The following are some currently utilized educational approaches:

1. Applied Behavioral Analysis (ABA) is based on learning principles and uses the ABC model to teach a child how to learn to focus on skills in attending, imitation, receptive/expressive language, pre-academics and self-help.

   In order to develop a skill it is broken down into small steps. To teach each step:

   –Antecedent. Therapist gives a clear instruction; and may provide a prompt by demonstrating or physically guiding the response

   –Behavior. Child responds

   –Consequence. Therapist reacts; gives a positive consequence or reinforcer that will lead the child to do the behavior again in the future

   Many opportunities or trials are given repeatedly in structured teaching situations and in the course of everyday activities. As the child progresses, guidance and prompts are systematically phased out so that the child responds independently. As steps are mastered, the child is taught to combine them in more complex ways and to practice them in more situations. Undesirable behaviors, or those that interfere with learning and social skills, are not reinforced. The therapist aims to reduce undesirable behaviors by removing the triggers and reinforcers of undesirable behaviors from the child's environment. New reinforcers are used to teach the child different behaviors. 

   Advantages of ABA

   • Recognizes the need for 1:1 instruction
   • Establishes clear objectives and collects data to assess effectiveness
   • Utilizes repetitions until learned responses are firmly embedded
   • Provides a "jump start" for many children
   • After two years of intensive individual intervention, ABA enables many children to function in regular school

   Disadvantages of ABA

   • Time-consuming: 30-40 hours per week for 2 years
   • Can overstress the child and family
   • Costly–up to $50,000 per child
   • Since it emphasizes compliance training, ABA can promote dependency on 1:1 and prompts
   • Heavy dependence on behavioral approach may contribute to the belief that behaviors are willful rather than a result of a neurological disorder
   
   
2. Treatment and Education of Autistic and Related Communication-Handicapped Children (TEACCH) is based on structured teaching in a variety of settings, including the child's home and school. The program involves a complete program of services; it modifies the physical environment to accommodate deficits, assesses children for individualized treatment, involves parents as co-therapists so techniques will be continued at home, trains professionals as generalists rather than specialists in psychology, speech, etc. TEACCH makes expectations clear by using visual materials, daily schedules and work systems. Language, imitation, social and cognitive skills are emphasized.

   Advantages of TEACCH

   • Often funded by public schools
   • Recognizes the need for lifetime support from early childhood to adulthood
   • Includes parents as co-therapists, thereby increasing confidence
   • Facilitates autonomy at all levels of functioning
   • Is compatible with other therapies and carryover of what is learned in the program to other situations is possibly better

   Disadvantages of TEACCH

   • Is less well studied than ABA
   • Classroom is non-inclusive and therefore may contribute to segregation
   • Uses independent work centers which may isolate
   • Sometimes single classroom may not provide sufficient training of staff or collaborative work with parents
   
   
3. Floortime is based on the work of psychiatrist Stanley Greenspan. It encourages the therapist to enter the child's world and play on the child's terms, gradually expanding the play to include new ideas. For example, if a child lines up toys, the therapist helps, then the therapist might limit the number of toys available so the child has to interact in order to get more toys. Slowly the child will expand his repertoire of play and learn to interact with others. The goals of floortime are two-way communication, logical thought, attention and intimacy, and the expression and use of feelings and ideas.

   DIR/Floortime (Development, Individual differences, Relationship-based) is a comprehensive framework which, in addition to Floortime, stresses various problem-solving exercises and a team approach with speech therapy, occupational therapy, educational problems, and, where appropriate, biomedical intervention. This approach follows the child's emotional interests to build successively higher levels of social, emotional and intellectual capacities.

   Advantages of Floortime

   • Play and positive social relationships are emphasized in order to increase social and emotional skills
   • Warmth, pleasure and reciprocity in relationships are stressed more compared to ABA and TEACCH
   • Focuses on turning child's actions into interactions
   • Parents are taught to engage their child in happier, more relaxed ways

   Disadvantages of Floortime

   • Floortime is less well studied than other treatments
   • Does not focus on specific areas of competency
   • Therapists may inadvertently take the lead by trying to get the child to do what the therapist thinks he should do
   
   
4. Social Stories is a technique developed by Carol Gray to help children with autism understand the social rules, how to interact appropriately with others (for example, focusing on who, what, when, where and why in social situations). Social stories address problems in "Theory of Mind," or the ability to put oneself in the place of another and to understand the point of view of another person. Social Stories is comprised of a specific series of perspective, descriptive and directive sentences which state the desired behavior in positive terms. The goal is to share accurate social information that is easily understood in a reassuring manner.

   Advantages of Social Stories

   • Tailored specifically for each child and addresses issues from the child's perspective
   • Flexible and cost-efficient

   Disadvantages of Social Stories

• Supportive data are anecdotal
• Depends on the skill of the writer and ability to take the perspective of the autistic person
• Pitfalls include: Including too many directive sentences; writing above the cognitive developmental level of the child, using complex language, not specific enough in describing a situation or the desired behavioral response

As research is conducted on the treatments described as well as on other treatments, the groundwork will be laid for the establishment of evidence-based interventions.