AUTISM : CURRENT ISSUES 9

These short notes cover a number of issues concerning autism, linked simply by the acquisition or reading of the articles on the part of the current writer at much the same time.

The initial section deals with the proposition that one may be able to teach the skill of pretend play; and this is followed by a description of a means of developing the ability to understand, and accommodate to, particular cues in a social setting thus to reduce stress.

Reference is then made to the particular risk that may be faced by children with autism in respect of one form of abuse; and the final section explores the issue of savant skill development and the possible relationship between savant abilities and elements of autism.

M.J.Connor April 1999

Learning to Pretend

Imaginative play is seen as a major first step in the development of academic as well as social skills in young children. As result of taking part in imaginative play, the children can gain social understanding and more refined communication skills.

A major diagnostic indicator of autism is the inability to engage in this kind of play or to use symbolic language and behaviour. However, some research undertaken with autistic children has demonstrated that it is possible to teach autistics to play imaginatively with other children given the right kind of stimulation, viz., structured and "dramatic".

The research undertaken by David Sherratt and described by Williams in the TIES sought to follow up existing evidence that it is possible to involve children with autism in a pretend play, as demonstrated in small scale studies involving children towards the upper end of the autistic spectrum. The intention was to examine whether children with a limited verbal and mental ages and with additional learning difficulties could also be taught make-believe, and, by this means, to increase communication.

In the classroom setting a typical activity involved reading a story to a group of children while the children acted out particular bits of the story. For example, while listening to the story of the Three Little Pigs, some children acted out how the fox might huff and puff in an attempt to blow down the houses, while other children watched the actions. It is inferred that the children will have been shown the actions which they could subsequently copy, and both the actors and the watchers can link what is being heard with what is being performed.

Observations have shown that the use and recognition of pretend play have become established, and that children with autism have engaged peers in pretend play rather than playing alone or continuing the earlier pattern of repetitive behaviours.

It is also encouraging to note that these changed behaviour appeared to have generalised to settings outside the classroom and that, for example, pretend play is increasingly observed at home by parents. Further, the learning seems to be long-term in that the children were still playing pretend games following their return to the school setting after a summer holiday.

Sherratt argues that the success stems from making the process fun through the use of drama and much exaggeration of gesture and expression; in other words the underlying feelings are made "gross" and more visible, while the pretend play gradually evolves from the initial point which involves simply copying and then supplying the actions to accompany a given scenario. It might be said to be another illustration of the way in which nothing can be taken for granted with children with autism, who need to be taken step-by-step through learning experiences which might be taken for granted among non-autistic peers.

Social Stories

The approach to working with autistic children involving "social stories" was developed by Grey (1994), and there is existing evidence that this approach can be effective in enabling a child with autism to understand cues and actions linked to specific situations and to become able to cope with those situations.

An outline of the approach is provided by Attwood (1998) who describes how the stories are written to describe the particular circumstances or situations which the target child finds difficult. Each story begins with the precise information to describe what actually happens in the situation and where it occurs and who is involved, such that the child can clearly see what occurs and when or how it occurs. The stories may also include desirable responses and can be effective in preparing a child to face new situations.

It is recommended that the stories should contain three types of sentence. Descriptive sentences simply describe what happens and where it occurs, and who is involved and what they are doing. It is suggested that the sentences should be as accurate as possible while including terms like "usually" or "sometimes" in order to help the pupil to cope with possible changes. Perspective sentences describe the feelings and reactions and behaviours of others in the situation and the reasons for their reactions. Directive sentences demonstrate desired responses to social situations and indicate to the child in positive terms what he or she should try to do in a given situation.

Ideally there should be between two and five descriptive and perspective sentences for every directive sentence in each story. Meanwhile, the social story should be easy to understand and limited to the vocabulary which is appropriate to the child's age and ability.

When a story is introduced, one would keep distractions to a minimum and the story should be read daily to begin with, and immediately before the target situation.

Carole Rowe (1999) describes the use of a social story in working with a year 2 child with autistic spectrum disorder difficulties (Asperger Syndrome) who was demonstrating major problems in respect of social interaction and communication, complaining particularly about noise and the presence of other children during lunchtimes.

To begin, evidence was gathered by interviewing the pupil himself, his parents, adults involved with him in the school, and by direct observation in order to identity precisely what social situation was causing the problem.

It transpired that the major concern was that the pupil refusing to enter the dining hall in order to have his lunch with the other pupils. He would demonstrate his distress by shouting, and struggling with the adult staff if any one tried to hold his hand in order to take him into the dining hall. Efforts had previously been made to explain how he should behave, and one had tried to shift his place in the dining hall in order to avoid having to sit directly opposite other children; and all the pupils had been reminded about keeping the noise to an acceptable level. In the interview with the pupil himself, it emerged that he disliked watching other children eat as well as being upset by the perceivedly loud noise in the hall.

A social story called "Lunch Time" was prepared according to the guidelines recommended, and this was presented to the pupil in booklet form and read to him before lunch time. Rowe reports his comment "Now I'll know what to do".

The following was the text of the story:

"Before lunch I am usually in the playground. A dinner lady tells me when it is time to go and have lunch. I get my lunch box and then I walk to the hall. When I go into the hall for lunch there are lots of people there. Usually it is not just my class. A grown up usually shows me where to sit. There are lots of children in the hall who are eating their lunch. Children often like to talk while they are eating. There are lots of children in the hall who are talking at the same time. If the children get too noisy a grown up asks them to talk quietly. Sometimes children forget to close their mouths when they are eating. I will try to stay calm and quiet if I see children opening their mouths when they are eating. I will try to eat my own lunch and not worry about the way the other children are eating their lunch".

It is reported that even after the first reading there was a change in the pupilís behaviour in that he collected his lunch when asked, and walked to the hall, sat at the end of the table, and ate his lunch with no problems. His behaviour was such that his support assistant was able to leave him on his own for a significant time.

The situation was monitored closely by the adults over a three-month period, and the key comments were consistently positive with the pupil reported to have happy lunchtimes. Meanwhile it was noted that he was eating all of his lunch and was obviously taking note of the story's final sentence about trying to eat lunch without worrying about the way the other children are eating their lunch.

For the first six weeks of the intervention, the story was read each day but the frequency was gradually reduced and was discontinued after twelve weeks. However, the positive behaviour continued and lunchtimes were no longer a cause for concern.

It is also noted that the pupil has been able to transfer the skills gained to other situations. For example, if he loudly tells other children to be quiet at the beginning of assembly, his support assistant reminds him that, in the story, it is a grown up who asks children to be quiet if they get too noisy, and the pupil responds appropriately.

It is suggested by Grey (opp.cit) that social stories are successful because they are visual, they identify social cues and provide accurate information for pupils, they set out expected behaviour, and they remove social interference.

It is also possible that the social stories give a child access to a "shared schema". In other words, the child is no longer dependent upon his own idiosyncratic views of the world but is able to appreciate and share common perspectives; and the social story can help the child to organise his own experiences into a framework which is common to any children. Although it may appear that a child with Asperger Syndrome has no social common sense, (s)he may be able to learn what to do in a range of situations if someone provides an explanation.... and the social story provides that explanation.

Rowe (opp.cit) concludes that the particular intervention described has been very successful and long-lasting, teaching a skill that can transfer to a range of situations. Encouraging results are being observed when using the technique with older children and those whose needs are more severe; and it is argued that this technique offers a valuable additional intervention which is firmly based upon an understanding of the characteristics of autism.

Children with Autism as Victims of Abuse

The condition known as Munchausen Syndrome by Proxy is a form of child abuse and describes a situation whereby the carer can report or even induce significant symptoms of illness in somebody else, and use these symptoms to attract medical services.

Randall and Parker (1997) suggest that the syndrome represents a complex situation and one which is parasitic because the victim is put at risk in order to gratify the abuser. It is relevant to discuss this kind of abuse in the context of children with autism because it is clear that children with very poor communication skills are at particular risk.

Earlier evidence has indicated that the children involved are generally below six years of age and, in the study completed by Meadow (1982), three of the six cases had mothers who themselves had shown symptoms of Munchausen Syndrome.... that is, there was a history of seeking medical attention for themselves by means of describing fictitious symptoms. It is also a common finding that many of the mothers concerned had nursing or some other training or experience related to medical practice. Fathers have been implicated although only quite rarely, and other carers or health workers have been implicated as well; but it is usually the mother who is involved in the majority of cases.

Randall and Parker continue by suggesting that anyone who can adequately communicate with other people such as medical staff is less likely to become a victim of this syndrome. The abuser will look for potential victims who cannot communicate in order to deny the symptoms or to complain about deliberate attempts to induce the symptoms. Alternatively the victim may be a child who is willing to collude with the abuser by entering into the pretence of some medical disability. Accordingly, those young children with developmental disorders like autism may well be ideal victims for abuse of this kind.

The authors describe a case study of a child with autism attending a mainstream class about whom reports showed considerable differences concerning observed health at home and school. Although apparently perfectly healthy when in school, the boy was frequently away on the grounds of ill-health and had an unusually high number of visits from doctors over a short period because of reportedly high temperature even though no physical abnormality was ever found. Subsequently the reports included a reference to intermittent or laboured breathing but again no actual problems were detected.

Therefore, the suspicion arose that This was a case of Munchausen Syndrome by Proxy (or Factitious Disorder by Proxy) especially when it became known that the mother was obsessed with health issues and had undertaken earlier training to become a radiographer. The suspicion was confirmed when it was noted that the child's health was entirely satisfactory in the absence of his mother; and a series of checks carried out while the child was in hospital revealed that the mother had induced a high temperature by piling extra bedding around the child and by turning up the heating.

The child was especially vulnerable because he lacked the ability to describe his experiences and was very dependent upon the carer, albeit abusive. The risk was compounded by the lack of understanding among care agencies or social services staff services concerning the behaviours of children with autism, and by the social isolation of the child or his assumption that his experience was common to any children.

The advice from the authors is to recognise that autistic children may be as frequently the victims of this kind of abuse as any other children, or that the incidence rate among autistic children may be all the higher. Concern should be particularly evoked in those cases where carers who present as highly attached to their children describe consistent symptoms in those children which are unsupported by a subsequent medical examination, and which disappear when the carers are not on the scene.

Savant Abilities and Behaviours

The concept of "savant" was first coined by Down (1887) to refer to some particular ability within an individual categorised as mentally retarded. The most frequently observed savant skills are linked to the visual arts (notably drawing), musical performance, and certain arithmetic skills including calendar calculating (where the day of the week is rapidly identified for any given date).

The review of studies completed by Miller (1999) has revealed that the common links among definitions are that the behaviour seen among savant individuals is exceptional against the norms, and that the skill in question is within the context of severe and wide ranging intellectual deficit.

However, the review has also demonstrated that the skills do consist of more than simple associations or lists, and that there is heightened sensitivity to structure or to the presence of some rule.

On the other hand, the expression of the skilled performance may be distinctive or restricted in some ways. For example, the savant artists will typically adopt one particular perspective in their drawings and have difficulty in switching from this perspective. Similarly, the musical savant may persist in a particular style of playing even when given extensive teaching. The ability to make calendar predictions is usually not linked to more general understanding of mathematical principles; and converging evidence suggests that there is a lack of ability to perceive or describe the processes involved in the skill in question.

It is noted that the original definition of savant syndrome involved a background of marked mental disability, but currently it is recognised that savant skill may operate against a background of mild or borderline ability categories as well. in respect of the relationship between measured intelligence and savant behaviour, there are a number of reported cases in which unusually high levels of skill have been observed in individuals with severe learning difficulty. However, there is some support for the suggestion that there is a positive correlation between the level of exceptionality and more general intellectual skills. Further, there is a trend whereby different cognitive strengths may be linked to particular savant skills. For example, there is some evidence that savants are superior to controls on a range of memory measures; and skilled artists may show particular ability in spatial tests such as the block design task with the suggestion that this reflects a lack of central coherence (and the autistic child may be at an advantage in being able to focus upon details rather than upon the overall features when it comes to reproducing designs.)

It has been suggested that particular motivational factors may underline some savant performance, or that the performance reflects some particular element within the situation. This school of thought holds that there is something within the motivational structure or in the situation linked to an individual's disability that makes the emergence of isolated but highly developed skills more likely. For example, it has been hypothesised that social isolation may commonly be experienced by those with severe learning disabilities and that the savant skill arises because resources usually devoted to social interaction are redirected to its practice.

Meanwhile, there is much evidence that savants are highly motivated to perform their skills and will spend a considerable amount of time with them. In other words, simple experience may play a large part in the development of these abilities as illustrated by the observation that calendar calculating can be acquired by initially naive subjects after a period of training.

hi respect of the possible differences between autistic and non-autistic savant individuals, observations have indicated that the savants were more likely to take part in a repetitive behaviour and were more likely to have a single interest and a greater obsessionality. One conclusion has it that some motivational predisposition to engage in repetitive behaviour may be a necessary condition for developing certain savant skills.

It appears that savant skills typically appear in the context of some additional pathology, for example, a sensory loss, or severe early illness, or learning difficulty. In particular, autism has often been seen as significantly involved in the appearance of savant behaviour and particular or narrowed interests are cited as characteristic descriptions of autism or Asperger syndrome

A number of surveys using parental information have suggested that a significant percentage of autistic children show special skills. For example, a rate of over ten per cent was reported by Rapin (1996). However, it is important to note that the nature and extent of the special skill were not observed independently of the parental reports such that there may be some over estimation of the exceptionality.

Nevertheless, the data do suggest a link between autism and the emergence of a special skills. It has been argued that certain features of autism play a particular role in the development of savant skills, and one model involves selected impairment of the left hemispheric functions such that skills linked with the right hemisphere are developed to an unusually high level. Two commonly observed savant abilities, drawing and music, represent skills linked with the right hemisphere, and it has been suggested that calendar calculating can reflect right hemisphere processing in that spatial awareness often appears as a significant feature in the individual's self-report of their calendar knowledge.

It is also interesting to note the interaction between language skills and savant skills, as illustrated by case where a child became less interested in drawing, despite the savant ability, and whose performance became less sophisticated as communication skills improved.

An alternative model is that there are several areas of pathological development in autism and that one major impact is that of perseverative attention and a focus upon one type of information (visual or auditory, for example) rather than true multimodal processing. This kind of model is supported by the observations of relative inflexibility in the savants' application of their knowledge or skill.

The general conclusion set down by Miller (opp.cit) is that while savant skills can be found in individuals not diagnosed as autistic, there is strong evidence for a link between infantile autism and the development of those skills. Further, there would appear to be a close relationship between particular pathology and exceptional skills; and the relative rarity of savant behaviour may be explained in terms of the particular combination of deficits so that, for example, savant skill would be more predicted among those individuals with autism who showed temporal or parietal deficits, or stimulus over-selectivity.

 

References

Attwood A. 1998 Asperger Syndrome. London: Kingsley Publishing.

Down J. 1887 On Some of the Mental Afflictions of Childhood and Youth. London: Churchill.

Grey C. 1994 The New Social Story Book Arlington : Future Horizons.

Meadow R. 1982 Munchausen Syndrome by Proxy - the hinterland of child abuse. Archives of Disease in Childhood 57 92-98.

Miller L. 1999 The Savant Syndrome - intellectual impairment and exceptional skill. Psychological Bulletin 125(1) 31-46.

Randall P. and Parker J. 1997 Factitious disorder by proxy and the abuse of a child with autism. Educational Psychology in Practice 13(1) 39-45.

Rapin I. 1996 Preschool children with inadequate communication. Clinics in Developmental Medicine 139.

Rowe C. 1999 Do social stories benefit children with autism in mainstream primary schools? British Journal of Special Education 26(1) 1-4.

Williams E. 1999 Play can pierce autistic shell. Times Educational Supplement, Briefing Section. 5th.February. Page 24.

This article is reproduced by kind permission of the author.

© Mike Connor 1999.

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