AUTISM : CURRENT ISSUES 20
This set of summaries of recently published material is concerned largely with describing and evaluating various strategies for the management or treatment of autistic spectrum disorders.
Initially, there is a brief reference to recent information about video-modeling, medication (respiridone), and diet.
Subsequently, summaries are provided of reviews of immunological treatment, metabolic approaches, means of developing communication, dealing with repetitive thoughts and behaviour, and facilitating socialization.
In respect of socialization, there is converging evidence and opinion that simply immersing a child with ASD in a mainstream setting among typically-developing peers may not be enough to bring about improved social interactions; specific strategies, involving either adults or peers, are a sine qua non.
M.J.Connor September 2001
Firstly, and briefly, one notes the work of Charlop-Christy et al (2000) who investigated the relative merits of using video modeling versus 'live' modeling for teaching children with autism.
Young children were presented with two similar tasks drawn from the existing curriculum, one associated with the videotape condition, and the other with a direct-observation condition. In the video condition, the children watched a tape of some target behaviour being completed by models ; while the other condition involved observing the completion of the target behaviour by models working directly in front of the children.
After the observations, the children were tested for acquisition and generalization of the behaviour in question.
The results indicated that the video condition was more effective both in terms of the children's acquisition of the task and of generalising the skills acquired.
The conclusion was that, while normally developing children learn easily through direct modeling, the video condition appears to be more motivating and attention-holding for children with autism.
(This is in line with existing evidence that such children may face, in a typical classroom situation, a level of stimulation which they are unable to filter or organise efficiently, so that an 'external' narrowing of the focus of attention replicates the necessary filtering action and creates a more effective stimulus for learning. Children with autism may learn more efficiently from computer-based approaches with their relatively finite demands upon attention or incidental learning capacities compared to the situation when a teacher is working with a group of children and there is a whole range of verbal and non-verbal cues and messages, both witting and unwitting, which may be hard for the children with autism to manage.)
A further brief report has held that risperidone appears able to reduce some of the symptoms of autism in young (pre-school) children who show marked behavioural problems such as aggression and tantrums.
Masi et al (2001) describe a study involving a sample of ten children between the ages of 3 and 6 years who were treated with a small dosage of risperidone. Seven of the children had been diagnosed with autism, and three with pervasive developmental disorder.
According to baseline and follow-up assessments using three separate measures (The Childhood Autism Rating Scale ; Children's Psychiatric Rating Scale ; and Children's Global Assessment of Functioning), there were small but significant improvements in the level of symptoms.
Some side effects were noted, and one child was removed from the study because of tachycardia, and another because of high temperature ; but no behavioural deterioration was observed, nor drowsiness.
The authors concluded that young children are more sensitive than older individuals to side effects following the use of more commonly-used drugs to counter maladaptive behavioural symptoms, and highlight the potential benefits of risperidone in reducing the severity of the impact of autistic symptoms.
A third brief summary supports the view that changes in diet can improve the symptoms among some individuals with autism
In a conference presentation, Kniker (2001) described how his research team has been investigating the hypothesis that insufficiently degraded proteins may leak from the gut into the bloodstream, and bring about ( in a way analogous to the effect of drugs ) some change in brain activity.
Evidence is presented that a small but significant number of children and adults with autism showed improvements after dairy products and wheat gluten were removed from their diets. In a second phase of the investigation, further foods were eliminated including soy products, tomato, pork, grapes, and buckwheat, and marked improvements were said to follow. Outcomes were quantified using the Autistic Treatment Evaluation Checklist to demonstrate clear changes in symptoms in nearly forty per cent of the sample during a three-month intervention period.
A note of caution was introduced in that, while dietary treatment may appear effective among some individuals, one should not infer that some abnormal response to certain foods has an aetiological significance for autism. Rather, any abnormal response to food could be a consequence of autism.
Further, Kniker stresses that multi-modal intervention, including behaviour management, and psychological or educational strategies, is still appropriate especially if improvements in cognition or mood may lead to new and different stresses or demands upon the individuals concerned, with implications for some impact on behaviour.
( his underlines other research evidence to the effect that stress may be greater in those individuals whose symptoms are towards the less severe end of the autistic spectrum, possibly because of their awareness of their own differences and their experience of difficulties and uncertainties about participating in day to day social interactions.)
Gupta (2000) begins the review of relevant research findings by describing how a number of factors have been suspected when it comes to the aetiology of autism, including genetic, immunological, and environmental factors, but argues that there is strong evidence to suggest that the immune system is significantly implicated in autism.
However, there is a problem in that, while a number of biological treatments have been established in response to observed immunological abnormalities, there has been no consistent evaluation of the strategies through properly controlled trials.
Gupta's review refers to converging evidence that, in individuals with autism, there appear to be anomalies in the nature or number of the various cells linked to the immune system. For example, natural killer cells which are significant in the defense against viral infection are decreased in around 40% of children with autism.
On the other hand, there is reference to that school of thought which holds that there are no cellular impacts ( inflammatory responses ) in the brains of children with autism and that the immunological changes have no causal significance.
In response, it is noted that the immunological system can influence the functioning of the brain through cytokines which have an effect like that of hormones, or by cell action upon peripheral areas of the brain.
This being so, trials continue to investigate the effectiveness of immune-based treatment, and various examples are given .... such as the use of pentoxifylline which has an impact upon cytokines, improves blood flow and tissue oxygen consumption, and enhances synaptic responses in the central nervous system. This substance has been used with varying dosages and time intervals between doses in cases of children with autism and there is evidence for improvements in behaviours associated with autism in a significant percentage of those cases.
While it is recognised that none of the studies included parallel control groups or placebo groups, and there was a common lack of some standardised and consistent measure by which 'formally' to assess behavioural changes, Gupta still argues that there is justification for continuing such investigations via double-blind and placebo-controlled studies.
A further example is given of the use among children with autism of intravenous immune globulin (IVIG) which has been used in the treatment of various antibody deficiency and autoimmune disorders. There is evidence that children between the ages of 3 and 12 years showed no adverse side effects but improved in behaviours ( such as greater eye contact, calmer manner, enhanced expressive speech, or decreased echolalia ) according to parental reports and direct observations on the part of medical professionals.
There appeared to be a positive correlation between the younger age of the children and the extent and rate of the improvements shown.
Gupta concludes by restating the belief that there is sufficient evidence by which to suggest a role in the aetiology of autism for the immune system and that larger and well controlled studies should be established.
This latter point is emphasied by Zimmerman (2000) in a commentary on Gupta's paper. He argues that, despite several well-documented alterations of the immune system in children with autism, there is still no 'compelling' evidence that these changes are causative or directly related to autism.
Although findings from studies in this field are promising, there is a need for further evidence for interactions between the immune system and the nervous system and for the mechanisms involved if one is to have faith in immunological approaches to treatment.
Zimmerman concludes that it remains possible that the anomalies observed in children with autism reflect a parallel disorder. Evidence is given to the effect that antibodies to several brain proteins occur in significantly greater numbers of children with autism compared to controls, but none of these are specific to children with autism and all occur in individuals with other neurological disorders or control individuals as well.
In other words, autoimmune mechanisms may appear to provide some plausible cause for autism or they may be important in a sub-sample of individuals, but there is no evidence to suggest that antibodies or any other immune anomaly can specifically impact upon the vulnerable neuronal networks or synaptic functions in the autistic brain in order to account for the selective cognitive and behavioural symptoms of autism.
Page (2000) introduces his review by noting how autism may be seen as a genetic disorder, but that the condition may be linked to a range of particular gene defects.
His review suggests that there is convincing evidence that at least some of these defects underlie metabolic disorders leading to abnormal reaction rates or concentrations of metabolites. Certain enzyme defects ( such as phenylketonuria[PKU] or neurofibromatosis ) appear associated with autism, but these cases are only a small number of the autistic population, and many other individuals who have these enzyme defects do not show autistic symptoms. Meanwhile, other enzyme defects may be associated with pervasive developmental disorders which differ in some way from autism.
In some cases of autism, there may be an abnormal concentration of a metabolite but no specific defect has been identified. ( The example is given of abnormally high or low excretion of uric acid.)
However, it is recognised that those measures which are taken to counteract the metabolic abnormalities can lead to a reduction of autistic symptoms. For example, a low phenylalanine diet reduces autistic symptoms in PKU, or the use of calcium supplements to treat deficiency can improve the symptoms of some autistic patients. There is evidence for improvements also in certain cases where vitamin therapy has been tried.
It is concluded that all such findings justify the suggestion that some forms of autistic spectrum disorders could have a metabolic basis.
Page goes on to describe a specific metabolic disorder (a pervasive developmental disorder associated with increased nucleotidase activity) which is associated with marked hyperactivity and impulsivity, minimal social interaction, and atypical emotional development. The individuals affected also show a delay in language and demonstrate neurological symptoms such as an awkward gait or impaired fine motor control. This behavioural phenotype differs from classic autism in that the hyperactivity or compulsivity observed are more significant than the lack of social interaction.
There is evidence that IVIG improves the immune functions and appears also to decrease the neurological and behavioural symptoms in individuals affected. On the other hand, it is not known by what mechanisms the increased nucleotidase activity is linked with autistic symptoms.
'Purine autism' has been defined as classic infantile autism combined with a rate of urate excretion greater than two standard deviations above the mean.
Page cites a range of studies which have shown that exclusion diets can bring about improvements in a range of symptoms including increased eye contact and social interaction, improved language, and reduced self-stimulation. Meanwhile, the use of a dietary supplement (allopurinol) to counter the level of excretion of uric acid appears also to have a positive impact upon learning and social behaviour .... although it is noted that other metabolic disorders with enhanced production and excretion of uric acid are not associated with autistic symptoms such that the mechansims underlying the aetiology of autism are not explicable in these terms.
Reference is then made to the many reports of the beneficial effect of the vitamins or nutritional supplements in the treatment of autism.
One of the rare studies of vitamin treatment which has incorporated controls (Kleijnen and Knipschild 1991) concerns the use of pyridoxine which has been demonstrated to improve autistic symptoms especially when it is co-administered with magnesium. The improvements relate to social behaviour, language, responsiveness, and reduced aggression.
Further, folic acid has been reported to decrease hyperactivity and to increase attention and social behaviour in some autistic individuals with fragile x syndrome, and also to have a positive impact upon autistic symptoms among some individuals with autism who do not show this chromosomal anomaly.
Other studies have shown that a high calcium diet or calcium supplements among individuals showing unusually high rates of calcium excretion can bring about improvements in language, eye contact, and coordination.
Page describes how the low casein and/or gluten diet is the one which has become most frequently used in attempts to manage autistic symptoms, and this diet appears to be most beneficial among those individuals who show enhanced levels of excreted toxic peptides. The removal via the modified diet of certain proteins associated with the production of these peptides is linked with increased social interaction, responsiveness, and language usage.
Finally, Page refers to the frequency with which people with autism suffer from bowel problems such as diarrhea or constipation. A number of these individuals are shown to have symptoms similar to those of coeliac disease, and to show increased gut permeability, which may be significant in that toxic substances may be allowed to pass from the gut to the circulation. Reducing the level of those peptides with a neuroactive effect can lead to a reduction in autistic symptoms.
The example is given of individuals with autistic characteristics who showed the excretion of unusual metabolites thought to be of fungal origin, and treatment using anti-fungal medication was associated not only with a reduction in the excretion of these substances but also in the autistic behaviours.
However, it is stressed that there is as yet no clear evidence for a correlation between unusual peptides in the urine and increased intestinal permeability, so that one cannot determine whether gut permeability is somehow causally linked with autism or is simply an incidental finding.
The conclusion is that it is unlikely that autism will prove to be a purely metabolic disorder so that the search for some general metabolic therapy for all cases of autism will not be successful. On the other hand, it is noted that some metabolic interventions can bring about improvements in some cases.
What is required is continuing study, with particular emphasis on larger samples, longer term follows-up, and controls.
As a precursor to a discussion of ways and means of facilitating communication in autism, Koegel (2000) notes that autism is marked consistently by a lack of spontaneous verbal and non-verbal initiations.
Research may have shown some skew towards reducing overt behavioural symptoms when there continues to be a major need for work on (social) communication. Whether the child with autism uses verbal means of communication or some augmentative and alternative system, the skills in question, and the encouragement of initiating and expanding contact, remain highly significant.
Even when these augmentative approaches are in use, such as the Picture Exchange System, or the use of communication books, etc., there may still be a problem with spontaneity ; and the skills learnt may not readily generalise. The children in question often continue to require continual adult prompting, failing to show the spontaneous use of the skills they do possess.
For normal language learning, the start of joint attention demonstrates a significant step towards mutual understanding and communication and this facility appears to have some intrinsic socially-motivating basis.
Among children with autism, there is a common lack of the behaviours linked to joint attention, such as pointing, giving and showing objects, or using eye gaze to communicate. This deficit appears early in children with autism and could even be considered a diagnostic pointer justifying enhanced observation and assessment.
When it comes to identifying those characteristics in children with autism which are associated with an enhanced probability of positive outcomes from intervention, there is an emphasis upon relatively high measures of verbal intelligence and the presence of functional speech before the age of five years. Children who respond best to approaches designed to build social and communication skills, and to enhance adaptive behaviours, are those who have the highest baseline scores of social initiations.
There is some focus upon devising procedures by which to teach these important basic skills. Behaviour programmes are used to increase the use of self-initiated questions or other spontaneous verbalisations, and the data suggest that enhancing such basic linguistic skills is linked to more favourable and wide-spread long-term outcomes.
There is long term awareness that the parents of children with autism have a critical role to play in the teaching and practising of basic linguistic skills, but it is also recognised that programmes have to be realistic to counter some practical difficulties.
For example, there is converging evidence that the demands associated with looking after a child with a significant disability greatly increases the stress in the parents. The parents themselves may experience limited opportunities for socialisation, and their social circle or participation in activities outside the home which involve the children may be decreased because of the challenging behaviours or idiosyncratic style of the children.
It is also pointed out that planning for children with autism can be particularly difficult because the skills in which there is a deficit, such as language and socialization, are acquired by normally-developing children with minimal direct intervention. Meanwhile, programmes that require parents to set aside particular amounts of time to work individually with the children can often increase parental stress. There is an implication, therefore, that programmes need to dovetail into family routines so that teaching can continue throughout the day both wittingly and incidentally in natural settings.
While there is a general view that early intervention is critical, and that there may be benefits to many children in proportion to the intensity of the intervention, there are still questions concerning how best to provide linguistic stimulation and opportunities for those children with autism who actively avoid social interactions such that there are few naturally arising opportunities for language teaching and learning.
Koegel makes a plea for research regarding when and where and at what level intervention should occur in seeking to develop linguistic and social skills. This becomes increasingly important in the light of the current emphasis on inclusion within local nurseries and schools and on greater interaction with other children, but when the majority of existing language programmes focus upon individual work and are not designed for use in social or natural community settings.
The significance of language and communication is further highlighted by epidemiological studies which suggest that a large majority of behaviour problems may have some communicative function. The problem behaviour may be linked to attempts to demonstrate anxieties or needs, and should not necessarily be perceived as maladaptive or non-compliant.
Older children or adolescents who can produce entirely correct sentences may still have problems with the pragmatic use of language or with eye contact, topic shifting, etc., all of which may be difficult for listeners to manage such that there are risks of rejection ; and the lack of social and peer acceptance will itself reduce learning opportunities such that there is established a negative cycle of limited social and emotional development. The children and young people still need to learn rules of language usage, to determine how to match behaviour to different settings, and 'to know when and how to say what to whom.'
Nevertheless, the complexity of the whole field of autism is further demonstrated by Koegel's reference to the significance of the social settings that underlie or support problem behaviours, the possibly large numbers of maintaining variables, and the nature of the interaction between appropriate and inappropriate behaviour which may reflect how well-established is the problem behaviour, the context, and the child's general level of functioning.
Dealing with Repetitive Thoughts and Behaviour
As a preface to their review, McDougle et al (2000) note that repetitive thoughts and behaviour are included among the typical characteristics of individuals with autism. Such behaviour is found to occur significantly more frequently in children with autism than in children with other developmental disabilities.
This 'sameness behaviour' might include the creating and maintaining of patterns, lining things up in rows, insisting that all possessions remain in exactly the same place, and rituals about eating or dressing or going to bed.
Reference is made to an earlier study of the authors to investigate differences between the behaviour of individuals diagnosed with autism and individuals diagnosed with obsessive- compulsive disorder ..... within which one characteristic is a degree of awareness of the unreasonable or excessive nature of the behaviours. Autistic individuals may lack the ability to gain some insight or to make some rating of their internal state.
Results of the study showed that adults with autism and with obsessive-compulsive disorder can be distinguished according to the types of repetitive thoughts and behaviour.
For example, the autistic sample were less likely to show behaviours with some aggressive or sexual connotations or to show behaviours involving hoarding or touching or or self-harm. The obsessive sample were also found to show significant incidence of cleaning, or checking, or counting behaviours. The repetitive behaviour in the autistic group was generally less well organised or complex.
When it comes to young children, however, the DSM-IV criteria for obsessive-compulsive disorder do not include any requirement that the individual recognises that the behaviour is excessive or unreasonable. This being so, there is an implication that, for this age group, there could be similarities in treatment for children showing obsessive-compulsive behaviours and for children with autism who display repetitive behaviours.
One form of treatment involves medication, namely, the use of serotonin re-uptake inhibitors. Five forms of this medication are available for use in treating obsessive-compulsive disorder.
The first study of the use of the anti-depressant clomipramine showed effectiveness among autistic children and young people with a mean of nine years in reducing symptoms of autism including repetitive behaviours ( Leonard et al 1989 ) ; but the authors review other studies with the conclusion that results have been mixed and some adverse side-effects, such as increased restlessness, nausea, impaired coordination, etc., can be observed, especially among the younger children.
Fluvoxamine has been said to have a positive impact on autistic individuals showing obsessive symptoms or social withdrawal and irritability. However, only one study ( by the present authors ) involved appropriate controls ; but the adult individuals in the study who received this medication compared to those who received a placebo were rated on a standard behavioural scale as showing considerable improvements. Among children and adolescents with autism, the treatment appeared less effective and to be associated with adverse side effects such as anxiety or increased hyperactivity, etc..
The use of fluoxetine has not been investigated in controlled studies, although there is some evidence of effectiveness in some young people with autism albeit with negative side effects relatively common. Reference is made to one study where children with autism up to the age of eight years were treated with this medication and more than half were said to respond either well or very well in terms of behaviour, cognition, and socio-emotional performance.
Sertraline also appears to have had no controlled efficacy studies, but reports involving small samples suggest that children with autistic spectrum disorder show improvement in symptoms of anxiety or repetitive behaviour when treated with this medication.
Paroxetine is yet another form of medication which lacks controlled studies but there are reports of some benefits in single case studies in terms of reducing symptoms, including irritability, temper, and interfering pre-occupations in a seven year old boy, and reducing self injurious behaviour in a fifteen year old boy.
In their conclusion, the authors restate their finding of a lack of controlled studies of the use of serotonin re-uptake inhibitors, while highlighting the mixed results from their use among children or young people with autism.
Some evidence indicates benefits in terms of reducing repetitive behaviours as well as social problems among individuals with autism, but there is also reference to the frequency with which the drugs can be both poorly tolerated and of limited effectiveness.
Meanwhile, it is noted that there may be a range of factors underlying responses to these forms of meditation.
For example, there is evidence ( McBride et al 1998) that significant changes occur in measures of serotonin function during puberty among young people with autism. Similarly, Chugani et al (1999) reported results from a brain imaging study showing that serotonin synthesis functions are disrupted in children with autism.
In other words, future research needs to include not only appropriate double-blind and placebo-controlled trials, but also to increase the size of the samples studied, to measure differential responses in individuals with different subtypes of pervasive disorders, and to seek optimal dosage levels to match chronological and developmental age.
Social dysfunction is among the most handicapping features of autism, and there has been much attention paid to ways of improving social functioning, most of which involve behavioural methods which define the target behaviours, the antecedents, and the consequences.
Rogers (2000) points out that there is now greater emphasis upon the ecology of children's social interactions in natural settings involving opportunities to become involved with peers who, themselves, may be encouraged to prompt and shape appropriate behaviours in the children with autism.
These peer-mediated strategies can take several forms.
Peers may be shown how to initiate interactions, or they may be taught to respond to the child with autism who has been prompted to begin an interaction by some third person, or they may be shown how to act as tutors for both scholastic and social activities.
Meanwhile, there is a reference to the critical significance of parental involvement in order to develop social and communicative skills as far as possible during the early, pre-school years.
Rogers' descriptions of interventions that enhance child-parent interaction include a reference to teaching the parent to imitate the child in his or her play with toys for twenty minutes a day for two weeks. Follow-up observations showed significant increases in the child's gaze upon the mother's face, increased numbers of different toys played with, and a wider range of types of play.
In respect of encouraging greater interaction with other adults, one notes the effectiveness of a script-fading procedure together with a single-word stimulus, the use of which prompts the child to approach an adult and to begin a quest for joint attention. The importance of using simple visual cues was underlined by this work.
When it comes to encouraging interaction with other children, reference is made to the work of Strain et al ( various publications, eg 1994) who have developed peer-mediated approaches.
Typically, peers are taught to initiate play interactions and to share their toys, while offering help or affection or praise. These skills are practised in role-playing with adults, and the peers are given cues to begin to interact with target children around typical play materials and activities. The peers are given positive reinforcement by adults for their efforts, but these are gradually reduced. The strategies have been found to be effective in increasing the social interactions of young children with autism, and their generalisation has been demonstrated in inclusive pre-school classes.
Among children well into school age, interventions might include self management techniques whereby children are helped to learn and practise appropriate verbal responses to the approaches of other children, and they record the number of successful responses which is matched by points awarded and exchanged at intervals for small tangible rewards.
Other approaches include video modelling, peer tutoring of specific tasks, direct instruction when an adult teaches a game to the target child alongside typical peers, and social stories.
The author concludes that children with autism can be responsive to a range of interventions designed to increase social engagement with other people, both adults and peers.
Evidence exists that this kind of engagement will have a positive impact on other behaviours even if not specifically targeted by the programme.
For example, the frequency of the use of verbal language and of novel language constructions increase alongside increases in social engagement.
In other words, social engagement appears to be a 'pivotal response', i.e., a significant skill that has a direct influence upon the attainment of other important skills without the need for direct training.
An important implication from the review is that increasing social interaction requires access to typically-developing peers ; social skill training organised by and with adults does not easily generalise to social interaction with other children.
Further, while inclusive school experience is emphasised as an important means of increasing the interaction between children with autism and typical peers, physical integration does not necessarily lead to social integration.
'Immersion' in the mainstream setting is not a sufficient provision in itself to bring about social interaction ; rather, there needs to be direct intervention, either through adult-mediated or peer-mediated approaches.
A similar view is expressed by Laushey and Heflin (2000) who concluded that simply placing typical peers and children with autism together may not be enough to enable the development of appropriate social behaviours. They may need to be taught how to imitate as a first step followed by direct teaching of 'initiation' skills since an immersion approach works only if the children concerned have the ability to observe, interpret, and imitate the behaviours of competent others. Children with autism are not likely to have such skills and will need access to adult- or peer-mediated strategies in order to develop them.
These authors also point out that adult support for a mainstream placement can have some counter-productive effects. The use of an adult 'shadow' can inhibit peer interactions and increase the child's dependence upon that adult. Instead, there are implications for early training in pro-social exchanges, and the role of the adult would include the setting-up of opportunities for their practice and consolidation.
(This is in line with a theme constantly expressed by the present writer - MJC - to the effect that inclusion has got to mean more than simply attending the mainstream school ; it must also involve identifying particular needs and establishing a programme to meet specific social and scholastic targets.)
In respect of Social Stories, Smith (2001) has evaluated their use with children with autistic spectrum disorders.
She begins by acknowledging some of the difficulties with traditional social skill programmes in respect of bringing together a group of children with largely similar levels of social scale at a given time to work with teachers, or psychologists, or therapists. There may also be problems in devising programme elements which are relevant to all the children, alongside pressures to justify attendance at these groups which will cause children to miss aspects of the academic curriculum.
For children with an autistic spectrum disorder there may be additional anxieties linked to the group-learning situation and to the typical reliance upon verbal skills.
All this being so, social stories are attractive given their visual format, use of simple language, explicitness and the focus upon a specific and salient situation, and their availability for repeated usage.However, there seemed to be no previous evaluation of this approach and Smith set out to examine the effectiveness of social stories for children with autistic spectrum disorders attending mainstream schools and a school for children with learning difficulties.
A training programme covering two half-day sessions was provided to staff in a cluster of schools, delivered by two educational psychologists and a teacher from the specialist school. The first session covered the philosophy and practicalities of social stories with much practice of the production of appropriate descriptive and directive elements.
The second session provided an opportunity to follow up the story-writing practice completed in the interim period and focused upon identified children.
A range of targets of the nineteen stories written as a result of the training was identified, such as reducing obsessional behaviour, reducing inappropriate sexual behaviour, developing friendships, etc..
Ratings of the effectiveness of the stories commonly fell well above the mid-point of the ten-point scale. Thirteen were rated between 7 and 10 with five of these awarded 10.
Further, subjective comments from staff and parents who used the approach referred to its enjoyable and practical nature.
During the training, a concern was raised about how to present a story to child especially when the child could not read it for himself. Another question was about how to engage more able adolescents in a story seeking to modify behaviours which the individuals themselves do not recognise as a problem.
In respect of the first concern, it was found that reading the illustrated and simply written story to the child was motivating and effective in itself ; while among the older individuals it was found helpful to put more emphasis on the visual components of the information, including computer presentation. In one case, merely placing the typed story on the student's desk for him to read appeared sufficient to lead to a change in behaviour.
It was also found that preparing a social story helped the adults to clarify their perceptions of the children's behaviour or the particular elements of the social situation giving rise to concern. It was possible, therefore, to focus more clearly on the skills the children needed in order to improve their behaviours.
Finally, Smith recognises that a social story itself does not teach a new skill, but it can provide information about, and prompting of, a skill which the child already has or is developing but which is not yet used fully or appropriately.
* * * * * * * * *
As a general conclusion from all the fore-going, the present writer - MJC - would suggest that there is more evidence that autism cannot be viewed as some unitary condition. Rather, the variation in type and level of symptoms, perceived aetiological routes, and responsiveness to interventions, would suggest a wide clinical range among the children all legitimately diagnosed as autistic, and the appropriateness of the concept of a 'spectrum' of disorders.
M.J.Connor September 2001
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Smith C. 2001 Using social stories with children with autistic spectrum disorders. Good Autism Practice 2(1) 16-25
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Zimmerman A. 2000 Commentary : immunological treatments for autism. Journal of autism and Developmental Disorders 30(5) 481-484
© Mike Connor 2001.
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