These notes begin with a summary of research which further investigates the nature of the atypical visual perceptual/attentional capacities or style in children with autistic spectrum disorder. The implications underline the problems in shifting attention, especially if the shift is in the nature of attention as much as in the focus.
The subsequent section reinforces the point about the anomalous nature of attention, with particular regard to the development of joint attention, and sets out ramifications for social interactions.
Reference is then made to a study of children's behaviours in the home setting rather than clinic or laboratory setting, but which still highlighted problems in terms of executive functions like goal persistence, planning, and avoiding distractors.
The final sections note the usefulness of social stories in dealing with incidents of overtly disruptive behaviour, and of a form of cognitive behavioural therapy to deal with anxiety in children with Asperger Syndrome.
In addition to the core characteristics of autism which form the “triad” of observable symptoms and behaviours, there is converging evidence for the atypical nature of visual perception or attention among children with autistic spectrum disorders.
For example, children with autism are frequently very efficient at identifying shapes within complex designs, or in completing the Block Design subtest of the Wechsler Intelligence Scale. Meanwhile, when copying designs, these children show an unusual and idiosyncratic style in that in that they might start with a local detail rather than the overall outline, and are not likely to be put off when confronted with “impossible” figures.
In their review of such issues, Mann and Walker (2003) describe the lack of theories and hypotheses exploring such visual anomalies, and the reliance upon the concept of weak central coherence as an explanation. This concept refers to the perceived deficit among individuals with autism in respect of looking for the overall meaning or the wide picture in any stimulus or situation, thus failing to integrate all the component bits of information into a coherent whole.
In explaining success in such a test as Block Design, it is assumed that looking at the whole pattern normally interferes with the ability to perceive the component parts and how they relate, but the child with autism is more easily able to examine the separate parts of the design without this interference.
Research with the “ Navon Task ” has explored the relationship between local and global perception.
In this task, the child is presented with some large shape made up of many small shapes. An example would be that of a large letter H made up of many repetitions of some other small letter. Immediately upon presentation of this stimulus, the child is asked whether it contains a given shape or letter. The target might appear at one or both levels, so it might comprise the overall shape, or it might be one of the many component shapes.
Existing research ( as reviewed by Kimchi 1992 ) has shown that normally developing adults generally encode the overall or global shape more fluently than the constituent shapes. This may be described as a “ global advantage ”. Further, when asked to look at the constituent or local shapes, there is a tendency for interference to stem from the overall shape, and this effect is described as “ global interference ”.
When it comes to individuals with autism, the prediction has been that the global advantage or global interference effects will be much less evident, and might even be replaced by local advantage or local interference effects.
However, findings have been inconsistent in that some samples of individuals with autism have shown a global advantage and global interference ; others have shown a local advantage and interference. Mann and Walker (op.cit) seek to explain these inconsistencies in terms of different sample sizes, of different ranges or levels of disability across samples, or of differences in the precise methodology in that, for example, some subjects have known in advance at which level, global or local, the target stimulus would appear such that the test is more of selective attention than of divided attention.
Among autistic samples, performance has been found comparable to normal control samples on the version of the task involving selective attention ; but with the divided attention task, the participants with autism typically failed to show the global advantage and interference shown by controls, and, instead, made more errors with regard to global than to local targets ….. although there are recognised to be problems in clear interpretation of data as a result of differences across studies in terms of the precise composition of the compound figure, the location of the stimulus within a visual field, etc..
Meanwhile, the typical individual with autism is found to show a relatively narrow spread of attention, and there is a common finding that he or she may be quite capable of focusing attention and concentration for prolonged periods ( especially when the topic is self chosen ), but there is a problem in shifting attention and in making the transition between one activity and the next.
The study completed by these present authors ( Mann and Walker ) sought to determine whether visual attention in autism tends to be spatially overfocused and whether there is some associated deficit in broadening the spread of attention. They employed a version of the “ Crosshairs Task ” where individuals are presented with a pair of stimuli, each made up of a horizontal line and a vertical line which bisect each other. The task of the participant is to say which of the two lines is the longer, and then, whether the second of the horizontal or vertical lines was longer or shorter than the first.
The assumption surrounding this task is that a decision cannot be reached by simply looking at the end points of the lines, but attention needs to be spread over the whole figure(s).
In respect of an autistic sample who might be thought likely to overfocus attention within a restricted region, the hypothesis was that there would be a more rapid and accurate response to the smaller crosshairs than to the larger ones.
Further, given the perceived deficit in shifting attention from a narrow focus to a wider one, the hypothesis predicted that an autistic sample would experience some difficulties in responding to a large second crosshair when the first crosshair was small.
In their study, a comparison was made of the performances of a group of children with autism ( mean age 10 years ), and control groups of children with moderate learning difficulty ( mean age 9 years ), and normally developing children ( mean age rising 6 years ).
The patterns of responding to the first stimulus showed no significant differences among the three groups, and there was no effect of the size of the first crosshair.
The absence of any size effect, and the lack of evidence that the children with autism were relatively good at responding to a small crosshair, contradicts that school of thought which argues that autism is associated with a relatively narrow attentional focus.
However, the autistic sample was found to be less accurate and slower in their responses when a large second crosshair was preceded by a small crosshair.
In other words, there appeared not to be a general deficit in controlling the spread of attention or in dealing with large stimuli ; rather, there appears to be a problem in the transition from dealing with small and then with large stimuli.
Thus, there is some support for the view that autism is associated with a deficit in broadening the spread of visual attention.
Meanwhile, the pattern of responding among the two control groups was largely similar, confirming that the distinctive pattern among the participants with autism was a matter of some specific autistic characteristic rather than of some learning disability.
The authors held that a deficiency in broadening the spread of attention could explain why autism might sometimes appear to be linked with an overfocus of attention. Once an individual with autism has focused upon a localised feature, he or she will find it hard to “ zoom out ”, and will remain fixed in their attention for a greater time than is observed among typically developing individuals.
This pattern would also explain some of the atypical visual behaviour frequently observed among autistic samples, such as the superior performance on the Embedded Figures Test or Block Design Test resulting from the reduced impact of the global aspects of a stimulus.
This is not quite the same as the Central Coherence Hypothesis because it does not preclude the possibility that an individual with autism can integrate local elements to produce a global form … only that they find it difficult to do so when this requires the spread of attention to be broadened.
Meanwhile, evidence from Rinehart et al (2001) has shown that high functioning individuals with autism responded more slowly to a global target that was immediately preceded by a local target than to a local target preceded by a global target.
They explained this in terms of some general deficit in shifting attentional set. This was held by Mann and Walker to be consistent with their findings and with their hypothesis that individuals with autism show a selective deficit in broadening the spread of visual attention.
( The present writer – MJC – would comment that this further evidence for the anomalous attentional style among children with autism highlights again the potential disadvantages in a typical classroom which, inevitably and appropriately, involves a range of activities and frequent shifts from one kind of task and attentional demand to another.
In particular, the child with autism may be a disadvantage when the session moves from some individual and quiet activity to a whole class discussion chaired by the teacher … ie a shift from a narrow to a broad perspective. The implication is for pre-planning for the child with an ASD, and providing an advance description about the structure of the lesson or session as a whole plus early warnings about impending changes in task demands ).
The work of Stahl and Pry (2002) begins with a review of studies which demonstrate poor executive functioning in individuals with autism of all ages. Executive functioning includes such cognitive components as planning, flexibility of thought, attentional set shifting, inhibition, and holding mental representations in working memory.
The hypothesis is that these executive weaknesses will underlie the perseverative and inflexible behaviours such as are found in autism.
However, what few studies exist of young children appear to suggest no early executive deficits but that autism-specific problems may stem from social weaknesses notably those related to joint attention.
In normal development, there is a strong association between joint attention (social) and attentional flexibility (cognitive), but it is not clear whether there is a similar association in autism.
Autistic symptoms relating to restrictive and repetitive interests and behaviour are the most obviously linked to deficiencies in attentional flexibility ; but it is not known at what precise age or stage of development these deficits are first evident. Are they present from a very early stage, or do they appear at a later stage, perhaps in response to more fundamental or primary disabilities ?
What little data that do exist ( eg Griffiths et al 1999 ) suggest that very young children with autism ( around 37 months ) are comparable to controls ; but at a mean age of 51 months, they make more perseverative errors than normal controls in tasks which call for some shift in attention. The implication is for an autism-specific weakness appearing with time and standing out all the more as normally developing children gradually improve their attention-shifting performance.
There is raised the further question of the possible impact of such a deficit upon other developmental areas, notably social deficits such as a lack of capacity to maintain joint attention with another person. In any event, it is evident that children with autism do show consistent impairments in joint attention behaviours including making and maintaining eye contact, looking towards another person, following the direction of gaze, and pointing.
The current study of Stahl and Pry examined three hypotheses ….
The target sample were below 7 years of age, and all diagnosed formally according to ICD-10 criteria. There were 15 children with a mean chronological age of 60 months and a mean mental age of 24 months. The control group comprised 21 normally developing children with a mean chronological age of 25 months.
( Ideally, a learning disabled sample would have been organised as a further control group, but this was not possible because of the difficulty in gaining access to such children and because of the frequent confoundability of diagnoses of autism and mental retardation. )
The set ( attention )–shifting element involved a series of tasks where an object is hidden in one of several locations. For one or more trials, it is hidden in location A, then in a different location, B. Continuing to look at A when the object is at B is deemed a perseveration error. Three tasks in rising levels of difficulty were used.
The joint attention tasks involved a situation where the adult placed a book in front of the child, waited, then turned to a page containing a familiar picture, then asked the child what it was. Reactions from the child were observed and scored.
Subsequently, the child’s capacity or willingness to follow the adult’s direction of gaze was examined ; and a further task assessed the child’s willingness to make eye contact in some ambiguous situation such as, when the child was playing with some toys, the adult prevented further actions by covering his or her hand for some moments. The child’s reactions were further noted and recorded.
The results indicated that, whatever executive dysfunction theory might have predicted, there were very few differences between the autistic sample and controls on the set-shifting task.
However, more autism specific deficits were found for joint attention.
There was also the clear suggestion from these tasks that the two skills are dissociated in autism but not in normally-developing individuals.
The authors acknowledge some limitations in this study, including the lack of data concerning the mental age of the control children, and the absence of a control group comprising learning-disabled children.
Nevertheless, they argue that the results are meaningful and comparable to existing research evidence such as those of Griffiths, and may be said to confirm the view that some components of executive function, such as set-shifting, seem intact at an early stage of development but show deficiencies at a later stage.
Since the joint-attention deficit is seen very early in the development of children with autism, this basic social impairment may inhibit the children from engaging in social interactions which, in turn, would normally influence flexible thinking and planning capacities. ( Support for this view is cited from infra-human studies showing that social isolation can lead to perseverative behaviours, self-stimulation, and problems in coping with tasks of any complexity ).
The authors also speculated whether their findings may reflect some dysfunction of the medial temporal lobe and limbic system in the brain, with the corollary that the functional integrity of these structures is necessary for the early development of social perception and cognition …. thus helping to explain the core symptoms of autism that are observable in the very early stages of childhood.
However, it is still not clear whether any such early limbic dysfunction would disrupt the development of higher cortical functions, and whether there would be some inhibition of the developmental stimuli and growth arising from opportunities for social interaction.
Whatever the speculation, the authors held that one can state with some confidence that the presence of some “ dysexecutive syndrome ” at an early stage may have important ramifications for ongoing cognitive development ; and what is needed is some clear system for assessing the presence or absence of the relevant cognitive capacities in young children since the ongoing inability to plan, reason, or think abstractly and flexibly, will be likely significantly to inhibit the child’s opportunities to learn and benefit from the environment.
Continuing the theme of executive function or dysfunction in autism, Ruble and Scott (2002) recognise how autism-specific impairments include an inability to engage in planning and goal-directed behaviours, or to adjust behaviour according to the demands of the immediate setting.
However, their concern was that evidence and opinion are based largely upon studies completed in the artificial world of the clinic or laboratory, and their own study involved a set of observations of children with autism, compared to children with learning difficulty ( Down’s Syndrome ) but matched on measures of mental age, in their day to day routines at home. The age range was 6 to 10 years.
In this study, written records of performance were compiled and analysed in terms of “ activity units ” defined as chunks of intentional and goal directed behaviour. Attempts were made to highlight what the child was seeking to do, what was actually happening, and what the child’s intentions were.
The units were also coded in terms of their length, and whether they overlapped with other units to form more complex behaviours with more than one goal.
Existing evidence from early attempts to use this ecological approach ( Wright 1967) has indicated that, among normally developing children, behaviour occurs in rapidly increasing segments and, with time, with more short-term units enclosed within longer units.
Further, with age, there is a greater capacity to maintain the goal-directed behaviours in the face of distractions.
The results indicated that children with autism produced shorter and less overlapping goal-directed behaviours. The data were taken as an indication that autism involves an actual cognitive difference rather than developmental delay, and there was support for the view of impaired executive functioning among individuals with autism.
The observed sample of children with autism showed activity units which were about half the length and involved half the amount of overlap compared to those of the sample of children with learning difficulty.
The limited overlap among the autistic sample was taken to reflect the relative difficulty in engaging in more than one activity at a time, and accords with existing evidence that such children have a particular difficulty in processing simultaneous cues.
In summary, the results highlight the autistic weaknesses in flexible control of attention, inhibition of competing stimuli, and maintenance and implementation of a plan.
In the classroom, it would usefully be kept in mind that likely characteristics of the child with ASD include some limitations in persistence with a task and in the ability to cope with more than one task or set of ideas at a time. The scope of attention, and of working memory, appear not to cope ….. ( especially, as indicated in the previous section, if the tasks are very different and if transitions from one activity to another involve a need for different types of attention ).
The compensatory need is for the provision of some schedule or visual timetable to reinforce the child’s own faltering capacity to plan and structure his or her work, and to bolster working memory.
The general principle as set out by the present writer – MJC - is that of taking nothing for granted in the case of children with ASD in terms of their awareness of the stages of a task, of their taking advantage of incidental learning, and of their capacity to cope with instructions given during their working on some assignment or directed to the class as a whole.
Still on the subject of managing children with ASD in the classroom, the usefulness of social stories has been highlighted by Scattone et al (2002) in dealing with overtly disruptive behaviour, as opposed to dealing with issues which have given rise to anxieties in the children themselves ….. ie social stories can focus upon problems produced by the child with autism as much as upon those experienced by the child with autism.
The authors cite the significance of disruptive behaviours in the classroom for the educational performance of both the child with autism and for his or her peers, as well as for the likely interference with social interactions and social development for the child with autism.
The unique value of the social story techniques may lie in its capacity to establish a routine or a rule, applicable to some setting or situation which idiosyncratically causes problems for the child with autism, and to establish some rule or routine that the child can then apply to that situation. The strategy is unobtrusive and can be geared to the specific and individual circumstances or needs of the child in question.
However, the authors recognise the very limited nature of existing evaluative studies, and note that it is unclear whether social stories used in isolation can be effective in enhancing behaviour and social performance, or whether they are more effective in enhancing behavioural deficits than in reducing behavioural excesses.
In their own study, the target boys were three diagnosed autistics ( two aged 7 years and one aged 15 years ) showing negative behaviours. All three were in self-contained special education classes attached to mainstream schools.
The first case was concerned with constantly tipping his chair backwards such that he frequently fell on the floor. The boy was capable of reading, and speech was adequately fluent.
The second case involved this older boy’s staring inappropriately at females (which commonly preceded masturbatory behaviours ). He also showed adequate speech and competence in reading.
The concern in the third case was about constant shouting out in maths lessons which not only disrupted the session but also led other students into shouting out as well. This boy was not self sufficient in reading the social story.
Baseline data were gathered and the intervention phase involved introducing the prepared story to the participants on an individual basis, and ongoing behavioural data were recorded. Observations and recording were undertaken by graduate students.
The observations revealed that all three boys demonstrated a reduction in their respective disruptive behaviours, with the greatest reduction shown by the boy whose target behaviour involved the chair-tipping. It was the third boy whose improvement was the least, possibly because of his inability to read the story independently.
The authors expressed confidence in the methodology but acknowledged that there were still questions about validity. For example, it was noted that verbal prompts, not planned as a component of the strategy, were used frequently by teachers in different ways or levels of intensity, in referring to part or all of the social story. The question was raised whether the behaviour would have been reduced by the social story alone or whether the verbal prompts were influential.
It was, therefore, concluded that social stories appear effective when organised according to the guidelines established by Gray (1998), but it has yet to be established what are the features of the social story strategy which are associated with the most positive outcomes.
Nevertheless, the authors felt able to commend the use of properly constructed social stories as a means of decreasing disruptive behaviours of some children with autism, and that social stories could be used effectively in the absence of planned and systematic behavioural interventions such as token economies.
The relevance of specific measures by which to counter anxiety among individuals with Asperger Syndrome is highlighted by the reference to this syndrome in DSM-IV which notes its association with secondary mood disorders, especially anxiety disorders.
It is further noted by a range of researchers ( including Piven and Palmar 1999 ) that Asperger children could be vulnerable to a genetic predisposition to mood disorders.
Meanwhile, circumstantial factors contribute to higher incidence of mood and anxiety conditions. For example, these children have characteristic difficulties with peer relationships and friendships, theory of mind situations, pragmatic language, literacy development, and sensory perceptions …. all of which may heighten feelings of stress which can precipitate a mood disorder.
All this being so, Sofronoff and Attwood (2003) describe an intervention specifically developed for Asperger children experiencing significant anxiety to teach them, according to the framework of cognitive behavioural therapy, to manage their feelings.
A further and important element of this intervention was the involvement of parents to act as co-therapists thus to increase the probability of the children’s being able to generalise the strategies learned in the training sessions.
The general scheme seeks to explain the role of emotions and their uses or misuses.
Cognitive restructuring is used to counter distorted perceptions and dysfunctional beliefs, to which end other strategies, such as social stories, can contribute.
A 6-session programme is described, beginning with an exploration of positive emotions and the identification of feelings during some preferred activity which utilises the individual’s strengths and talents. This was linked to a system for providing some measure of positive affect involving the participants’ determining where to stand alongside a length of rope stretched across the floor, while identifying cues about feelings gained through expressions or thoughts or body language.
This was accompanied by work on relaxation techniques, and the changes in thoughts and physiological cues when feeling relaxed.
Subsequent sessions explored the nature of anxiety and the underlying reasons for such a feeling together with identifying the physical or psychological changes which reflect anxiety ; and there was a discussion of the means of challenging the maladaptive thoughts which stimulated or maintained the physical signs of anxiety. In particular, antidotes to negative self-perceptions were identified, such as “ I can learn more from mistakes than from what goes well ” instead of “ I always make mistakes ”.
Measures of success included parental reports of their own capacity to work with the children along with observed and positive changes in the children, together with a specific measure to identify changes in the children’s capacity to generate strategies for managing the reported anxieties in a described case.
The authors concluded that, given the frequency with which anxiety is associated with Asperger syndrome, it is important that there are structured and tried strategies by which to intervene in the early stages of the development of an anxiety disorder.
The present study is held to be indicative of the effectiveness of a form of cognitive behavioural therapy with such children and is, at least, a starting point …. with implications for ongoing studies to determine the effectiveness of the use of peer co-therapists in a school-based programme, and whether the strategies can be extended to deal with more severe anxieties.
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© Mike Connor 2003.
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