This set of notes begins with a brief re-reference to the issue of inclusion and associated concerns, with support for the concept of a range of educational provisions.
The next section concerns the means of accurate diagnosis of autism and ASD among young children, and refers to a number of principles for enhancing validity which have emerged from a range of studies.
Reference is then made to further indications of what constitutes or characterises autism, including the patterns of brain activation in response to certain stimuli, genetic bases, and the underlying roots of repetitive behaviour or stereotypies.
The final section describes the potential value of Precision Teaching and Video-Modelling as interventions for children and young people with autism and ASD.
As addenda to the recent notes in this series (Inclusion and ASD-January 2006), one notes the minutes of the All Party Parliamentary Group on Autism (30 November 2005) which discussed the education of students with different disabilities and whether they should be taught together or separately.
The starting point was the reported outcomes of a survey among samples of mainstream teachers where an overwhelming majority supported the teaching of students with dyslexia or dyspraxia alongside other students, and where there was also a general, albeit less strong, view that pupils with sensory difficulties should be taught within mainstream groups.
Teachers were more divided on whether students with autism should be taught separately, with resistance to inclusion most evident among secondary-school teachers largely because of concerns over behaviour.
Opinion from the TES editor who organised the survey held that students with autism are perceived by teachers as the group that are hardest to teach; with the possibility that the rate of movement of such students away from mainstream schools is linked to the teachers’ perceptions of being unable to manage … or that parents come to the conclusion that their children cannot cope adequately in the mainstream schools.
A representative from Parents Autism Campaign for Education expressed concern at the lack of viable choice for parents when it comes to education of their children with autism, and that real choice will only become available when (mainstream) schools are provided with adequate support or resources and when teachers have a high level of expertise via ongoing training.
(One might argue that this kind of debate exemplifies well the kind of transitional status currently applicable to SEN planning, or to general educational planning, where there is a growing consensus over the principle of inclusion but anxiety over the practicality in terms both of resourcing and also of pressures about producing observably higher and higher standards of achievement and gaining a place in the upper regions of league tables. Many schools may show innovative inclusive practices and a flexibility in curricular goals and presentation, but it is not yet the case that such practices gain the appropriately full recognition in national and published statistics.)
The issue of full awareness of the nature of autism and ASD, and of individual variations therein, becomes all the more significant because of the largely hidden nature of the difficulties or idiosyncrasies; and further anxiety expressed at the All Party Group meeting was concerned with the governmental move towards school autonomy in determining admission policies and criteria with the possibility that, whatever the stated intentions, the actual outcome could increase selection to at least some degree … (and, presumably, a widening of the difference between schools perceived as effective and those perceived as failing according to existing and formal achievement criteria and in the absence of criteria linked to emotional and social and life-skill development).
Parental contributions to the discussions included a reference to the need for the opinions of the students to be elicited and acted upon, and to the need for caution about demanding that all students should be taught in mainstream, with the opinion that one can identify examples where it appears more inclusive to be in a specialist schools.
There was also some anxiety about arrangements for the students when they leave schooling and make the transition into the adult world.
(Again, one is reminded of the view that what matters is not so much where the education is provided, but what is contained within the curriculum and how it is delivered. A range of provision will be required to match the range of need so that some students with autism and ASD will be rightly placed in mainstream schools, while other students will require very specialist provision, with a spectrum of opportunities between these two extremes to meet the needs of the population of children and young people.)
A return was made to the issue of teacher training, and the right of children with autism to be taught by teachers who have skills and expertise in autism education; with the outcome of the survey seen as highlighting the crucial nature of initial and continuing training, whole-school autism awareness, plus access to external professional advice.
It was further stressed that flexibility is the key while recognising that inclusion will mean different things to different individuals … with the recognition of the need for high levels of support even for academically-competent students because the problems encountered may be more to do with social issues and anxiety about informal interactions than with in-class performance (which further highlights the need for peer awareness-raising about the nature of autism).
The over-view paper by Lord and Luyster (2005) describes the various screening and early diagnostic instruments by which to identify children with autism and ASD.
They begin with a reference to the Checklist for Autism in Toddlers (CHAT : Baron-Cohen et al 1992) which emphasised joint attention and imagination. Their survey suggests that most children picked out as at risk by CHAT were later diagnosed with autism, but their concern is that there were many children whom this instrument failed to identify but who were subsequently diagnosed with ASD.
They describe, next, the modified version of the CHAT (Robins et al 2001) for use with children of around 2 years which placed more weight upon the parental opinions and observations, with reasonable accuracy in aiding later diagnosis … albeit with the concern lest the apparent validity and reliability are a function of the non-random nature of the population tested (all recruited from specialist pre-school provision).
The Early Screening for Autistic Traits (ESAT : Willemsen-Swinkels et al - in press) puts more emphasis upon play than upon joint attention. The outcomes of trial use indicated that children with high scores on this measure were likely to have significant developmental problems but, for children below 24 months, there was limited differentiation between ASD and non-ASD needs.
There were also many children not picked up by this measure who were later given an ASD diagnosis.
The Communication Symbols Behaviour Scales (CSBS : Wetherby 2001) are questions for parents to identify communication weaknesses rather than ASD specifically among children between 6 and 24 months. If a positive indicator is gained, the child in question would be assessed on a further questionnaire and a direct observation of behaviours.
The Social Communication Questionnaire (SCQ : Rutter et al 2003) is also a parental questionnaire intended as an initial screen and children seen as at risk would be referred on for more specific assessment. It can be used with children and young people across a wide age range, but may not be very meaningful for children below 3 years of age. A practical issue lies in the fact that the children studied had already been referred for services so the value of the SCQ with the more general population is not certain.
The CARS and GARS are both intended for basic screening, and as indicating the area or severity of symptoms, but are not seen as appropriate for use as diagnostic instruments.
The authors describe the usefulness of screening instruments as mixed, with the need for follows-up of children perceived as being at risk, but with concern lest some children who are at risk for developmental disorders are not readily identified.
They suggest that, to add to the outcome of actual screening inventories, one investigates whether or not there exist further indicators which long-term observations have shown to have predictive validity. For example, there is the pattern of regression between around 13 and 24 months seen in about 20% of children who are eventually identified with autism when language development ceases and existing skills are lost and when a greater degree of withdrawal is noted.
Further, there are various qualitative social limitations or actual deteriorations in the extent of contact, use of gestures, eye tracking, shared attention, non-verbal language, etc. ; and parents may begin to describe the child as being in a world of his/her own.
Significant delays in receptive and expressive language can also be a valid reason for concern in the case of children who have no hearing problems and who have met motor milestones. Similarly, a child of around 2 years who has a reasonable “factual” vocabulary including, for example, letter names or colour names, but no “social/emotional” vocabulary such as “ mummy” or “dada”.
A referral to a speech and language therapist would be the next step and then onto a multidisciplinary assessment to determine if the issue is specific to language or is a reflection of ASD.
The authors draw 4 basic implications from their review ……
Ongoing work by Dapretto et al (2005) is exploring the actual neural functioning (or impairment of function) associated with those symptoms which are characteristic of Autism and ASD.
In particular, this research team has identified how abnormal activity in neurons associated with imitative behaviours may underlie some of the social anomalies observed in these conditions.
The findings indicated that impairments in interaction and empathy with other people (Theory of Mind) were linked with reduced brain activation in given areas, notably the “ mirror neurons ” located in the inferior frontal gyrus which is known to be implicated in social learning and awareness.
The lower the level of activation, the greater the social weaknesses.
Animal studies have shown that these mirror neurons fire both when the organism is observing another carrying out some action and when it performs the same action. Dapretto et al studied brain activation patterns of 10 children with autism as they passively watched or sought to imitate facial expressions representing the emotions of fear, anger, sadness, or happiness; and their reactions were compared to those of a control group of children matched for age and general ability but not autistic.
The sample of children with autism were shown to be able to perform the actions, both watching and imitating the expressions, but the level of activation in the specified brain areas containing the mirror neurons was lower than that noted in the control sample.
It was also noted that there was reduced activation in those areas associated with emotion – the insula and the amygdala.
The authors held that this mirror neuron theory of autism could provide a means of accounting for many of the signs and symptoms of autism.
(One might also draw the implication that this kind of study provides more evidence against any residual hypothesis that autism and ASD have a purely psychogenic source, but that autism is a “tangible” condition with observable physical correlates).
Meanwhile, the authors speculate that the target children are able to complete the imitative task by means of more superficial visual and motor clues rather than by an identification of the actual emotions inferred by the expressions.
Nevertheless, commentaries, including that of Rutter, suggest that more studies are required to determine how this particular element of neural functional anomaly dovetails with other elements … (and one might perceive the implication as that of supporting the view that autism and ASD are conditions whose range of levels and severities of symptomatology suggest multi-aetiological bases).
A similar area of study is described by Dawson (2005) who has examined face processing among individuals with autism.
She introduces her work by highlighting how autism is characterised by impairments in social and communicative abilities, often manifested by impediments in the use of eye contact and in minimal responses to emotional cues … and retrospective studies of home videotapes often show that children eventually diagnosed with autism show this failure to attend to other persons’ faces or speech from as young as 12 months.
This suggests a general dysfunction in the social brain circuitry, particularly in those systems involved with face processing which are usually established very early in life.
Her review of studies includes the converging evidence that there are impairments in the activation patterns of the parts of the brains of individuals with autism which are specialised for recognising faces or for recognising the meaning of the facial expressions, namely the fusiform gyrus and the amygdala.
Instead, when presented with such stimuli, there is activation of the brain areas involved in the processing of objects; and the ongoing implication is that autism is associated with a constant pattern of atypical neural responses to faces, notably an absence of the normal cortical specialisation for face processing.
Dawson describes two general theories which have arisen to deal with these findings.
Firstly, face processing impairments are seen as a matter of perceptual/cognitive limitations such as a failure to extract the relevant information from faces, or a dysfunction in the specific neural mechanism that supports face processing (such as the fusiform gyrus).
Secondly, it is held that face-processing deficits are secondary to faulty input to the neural systems during sensitive periods when the systems are developing. This social-motivation hypothesis indicates likely problems in attention to faces as well as to other social stimuli such as voices and gestures.
The implication, particularly from this second hypothesis, is that it should be possible to prevent or reduce these face-processing anomalies in autism via early intervention designed to draw attention to faces and speech and offering meaningful rewards for positive responses from the children.
It is Dawson’s hope that, by discovering autism susceptibility genes, it will prove possible to identify neonates at risk for autism and to provide very early intervention to maximise stimulation to the developing (social) brain systems.
So, on the subject of genetic susceptibility, one turns to the work of Buxbaum (2005) who starts with a restatement of the significance of genetic influences in autism, as illustrated by twin studies where concordance rates have been shown to be significantly higher for monozygotic than for dyzygotic pairs; albeit with a recognition, too, of the significance of environmental factors in some or many cases.
The review of studies indicates that ASD is a matter of complex aetiology with more than 1 gene responsible for the disorder and, in all probability, with the actions of multiple genes combining to lead to the disorder.
Buxbaum refers to causal genetic variations and to the significant number of cases of ASD which can be attributed to recognised chromosomal abnormalities involving multiple genes.
However, he also refers to susceptibity gene loci which refer to those many genes whose effect is limited and are not seen as directly causal, but which increase susceptibility to ASD; and ongoing work is seeking to determine which of these are of the greatest significance (with particular attention upon genes which play a role in neural transmission, or in the inhibition of transmission by which to reduce anxiety; or in the control of serotonin; or in the regulation of mitochondrial function in maintaining the energy level of cells).
The implication is that the susceptibility gene loci are many and various, but, in themselves, they have limited significance. What matters is the combination and interaction of multiple susceptibility loci which may be such as to bring about the signs and symptoms of autism and ASD …. (and one might speculate that it is the interactive action of these genes which will cause some individuals and not others to be at risk for the effects of some environmental “triggers”).
Buxbaum’s conclusion cites the empirical evidence that ASD can, in at least some cases, respond to intensive behavioural interventions so that identifying those very young children with enhanced risk for ASD linked to the identified pattern of susceptibility genes may well have practical and positive outcomes.
As a balance to the earlier discussion about affective anomalies and theory of mind, one notes the current work of Rogers and Ozonoff (2005) who feel that the current neuropsychological emphasis is over-weighted towards cognitive models and that there remains an inability to account for the characteristic symptoms of autism and ASD which involve repetitive behaviours, sensory abnormalities, and behavioural inflexibility.
It has been suggested that repetitive behaviours have sensory bases and that the fundamental issue is marked hyper-arousal or hypo-arousal, but this kind of hypothesis has not been adequately explored.
Meanwhile, there continues to be a view that sensory dysfunction is a matter of impairment in sensory integration whereby the individual cannot organise and make sense of (integrate) the range of incoming sensory information, with abnormalities in the function of the hippocampus seen as a significant and underlying issue.
A physiological basis for poor integration has been proposed in terms of abnormal and increased levels of serotonin in significant numbers of individuals with autism, which would impact most upon the neural pathways associated with language production as well as with the integration of sensory information.
The over-arousal theories hold that children with autism are more aroused by, and reactive to, sensory stimuli and cannot readily habituate to the stimuli in their environment.
Under-arousal theories commonly implicate some deficiency in the reticular activating system such that the child is unable to link existing experiences with previous experiences, and inactivation of the limbic system which leads to a barrier towards incoming stimuli as well as to a failure to respond to rewards or to engage in emotional learning with the result that behaviour remains repetitive and apparently aimless.
There is a lack of social interest and their attention is more directed towards the physical and tangible world.
Reference is made to the concept of perceptual inconstancy which encompasses a view of autism as a matter of primary problems in perceptual integration and secondary problems with regard to language and social skills.
Autism is seen as a matter of abnormal states of arousal due to brainstem abnormalities leading to a fluctuating state of under- or over-arousal such that the child cannot maintain perceptual constancy, and the repetitive actions are a form of compensatory strategy.
The authors describe their review of empirical findings in this general field and conclude that differences in sensory responses (behavioural and physiological) are linked to both general developmental effects and to specific developmental disorders.
Parents of children with autism, fragile X syndrome, learning difficulties, etc., all report higher levels of abnormal sensory responses than parents of typically-developing children.
The differences are most clearly observable when chronologically age-matched children are compared; and it appears that abnormal sensory responses are not specific to autism.
Meanwhile, it remains unclear why there are unusual responses to sensory stimuli in autism and the theoretical emphasis upon abnormalities in general arousal or in habituation to stimuli has not been supported by empirical evidence.
It appears, therefore, that, currently, one can challenge the theories of sensory defensiveness which suggest that the ignoring or rejecting of incoming stimuli is a way of avoiding over or under- arousal.
Further, the theory that repetitive or stereotyped behaviours serve to reduce high arousal levels is not supported, as illustrated by the quoted finding that stereotypies did not increase as the level of sensory stimulation impinging upon participants with autism was heightened.
Similarly, there was limited evidence to support the view that the repetitive actions are designed to increase arousal levels, although there is a suggestion from some studies that autism is associated with under-arousal.
One might currently question, therefore, the view that motor stereotypy specific to autism is a matter of regulating stimulation and the associated levels of arousal, especially with regard to postulated over-arousal.
One alternative explanation is that the lack of typical responsiveness to sensory input could be part of a more general issue of affect … the stimulus barrier view.
Another alternative concerns the possibility of some kind of early input deprivation or anomaly, impacting upon subsequent developmental opportunities and linked to impaired social capacity such that the child seeks compensation for the “unreachable” nature of social stimuli by focusing upon the world of objects and physical attributes and using the repetitive behaviours to create input for themselves.
The authors conclude that much more empirical investigation is required … especially in the light of what they see as widespread recommendations for sensory integration therapy as a necessary intervention.
In particular, there is a need for studies where there are clinical control groups matched for age and IQ as well as control groups of normally-developing children, and for the range of actual ages and mental ages to be kept narrow.
Studies should be repeated at various age levels with the means of recording both physiological and behavioural responses, with more emphasis upon controlled laboratory studies and less reliance upon parental questionnaires.
They repeat that current evidence is not very supportive of any hypotheses concerning the specificity of sensory dysfunction to autism; but there is a great deal about the unusual sensory responses in autism that has yet to be understood.
On a different tack, one thing that does seem to have become clearer is the role (or non-role) of immune deficiencies in autism.
Mazer et al (2005) describe how immune deficits have been put forward as possible aetiological factors in autism, or how an association has been suggested between such deficits and the presence of autistic symptomatology.
Their study analysed data from samples of children with autism and ASD and it was concluded that most children with these conditions have normal immune functions.
They concluded that routine immunologic investigation is unlikely to be of benefit in the case of most children with autism and should be undertaken only when there is a history indicative of recurrent infections.
In this final section, there is a reminder of the way in which 2 existing and well-tried teaching methods could be of particular relevance to children and young people with autism.
Firstly, reference is made by Bernard-Opitz (2005) to Precision Teaching which evolved from the traditions of direct instruction and behavioural approaches and which focuses upon specific teaching targets and upon the checking of consolidation such that the performance of the skill in question is fluent.
The specificity of targets and the repeated probing to demonstrate mastery and fluency may well suit the style of children with autism, especially as there is no direct competition against the performance of other individuals but the child in question seeks to beat previous performance in terms of speed of completion of a task or the reduction in errors.
Precision Teaching breaks down long term or major goals into small and manageable component parts which are the focus of small teaching and learning steps to be attained within given periods. Fluency is a critical element and there is a monitoring of performance so that one only moves on to the next teaching and learning step only when the current step has been fully mastered to the point where execution is rapid and virtually automatic.
It is noted that this approach can encompass behavioural and social goals as well as scholastic goals, such as imitation or eye contact or joint attention; and it is argued that children with ASD present with a variety of challenges which call for a range of intervention and teaching methods.
Precision Teaching is seen as one such method which can facilitate curricular decisions, ensure appropriately-sized teaching and learning steps, and reduce the efforts involved in gaining meaningful progress.
Secondly, with regard to behaviour, one notes the work of Pasqualetto and Thompson (2005) in seeking to make use of the particular interests or styles of children with autism in planning interventions. In particular, they recognised that many children seemed to struggle when faced with (verbal) instruction, but could attend well when the same material was presented via video-taped programmes.
They used the case example of “James”, a primary school pupil who found it very hard to keep on task in group sessions or to avoid distractors, coupled with problems in turn-taking or grabbing the materials, or in basic compliance with classroom rules and routines.
These authors tried video-modelling, where a given child observes filmed models correctly performing some task, reassured by the positive evidence from existing trials where video-modelling has been used to teach a range of skills such as conversation, shopping, and initiating social interactions, and where learning speed has been enhanced and the skills have generalised to further settings.
A sub-group of children (including James) were involved in an exercise where activities were to be filmed …. which, in itself, appeared motivating …. and they acted out specific skill sequences such as taking turns during games or activities with construction materials.
The completed films were subsequently shown to the group of children, and this was followed up by the sharing of sequences of photographs featuring the activity.
All the group focused well on the film and photographs, and James was observed to show markedly enhanced patience, keeping his hands to himself and waiting for his turn, and improved proficiency in solving the challenges presented by the game.
The authors acknowledge that there are many issues and problems associated with ASD and, correspondingly, a whole range of potential interventions, and that what works well with one child may not have any impact with another. However, it is suggested that video-modelling is an approach with demonstrable potential benefits which would usefully be added to the existing range.
Baron-Cohen S., Allen J., and Gillberg C. 1992 Can autism be detected at 18 months ? British Journal of Psychiatry 161 839-843
Bernard-Opitz V. 2005 Precision Teaching : making learning effortless. Autism News of Orange County 9-10 (Summer/Autumn 2005)
Buxbaum J. 2005 The genetics of autism spectrum disorders. Medscape Psychiatry and Mental Health 10(2) December 2005
Dapretto M. et al 2005 Copying nerves broken in autism. Original study in Nature Neuroscience; summary published in news.bbc.co.uk
Dawson G. 2005 Face processing in individuals with autism. Medscape Psychiatry and Mental Health 10(2) December 2005
Lord K. and Luyster R. 2005 Early diagnosis and screening of autistic spectrum disorders. Medscape Psychiatry and Mental Health 10(2) 27 December 2005
Mazer B. et al 2005 Immune function in autistic children. Summary published in Reuters Health Information (January 13th 2006); original article in Annals of Allergy, Asthma, and Immunology 95 (December 2005) 558-565
Pasqualetto M. and Thompson W. 2005 Video modelling. Autism News of Orange County 15-16 (Summer/Autumn 2005)
Robins D., Fein D., Barton M. and Green J. 2001 The modified checklist for autism in toddlers. Journal of Autism and Developmental Disorders 31 131-144
Rogers S. and Ozonoff S. 2005 What do we know about sensory dysfunction in autism? Journal of Child Psychology and Psychiatry 46(12) 1255-1268
Rutter M., Bailey A., Lord C., and Berument S. 2003 Social Communication Questionnaire. Los Angeles : Western Psychological Services
Wetherby A. 2001 Communication and Symbolic Behaviour Scales Developmental Profile. Baltimore : Brookes Publishing
Willemsen_Swinkels S., Dietz C., Van Daalen E., et al (In press) Journal of Autism and Developmental Disorders.
© Mike Connor 2006.
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