Tuesday, March 27, 2012
Medical Diagnosis verses Educational Eligibility Determination
Many parents don't realize that separate eligibility criteria exist for special education services and that a medical diagnosis alone does not make a child eligible for special education services. Although many of the disabling conditions that a child in special education may have are or can be diagnosed medically, the criteria for special education is derived from Federal law and State education code. Criteria for special education are developed by a political process that is informed by experts in the field, whereas medical diagnostic criteria are developed by experts in a process within the field of medicine. As such, the criteria and the categories themselves differ in special education than the corresponding disease criteria and categories in medicine. For example, although the category of emotional disturbance exists as a disabling condition in special education, but no such medical diagnosis exists in the DSM-IV-TR (the diagnostic manual used in psychiatry and psychology). The category of emotional disturbance, rather, is a catch all category for a variety of different mental disorders, behaviors, and social-emotional characteristics. Criteria may be different as well, for example the State of Oregon places a greater emphasis on sensory issues within the eligibility criteria than does the DSM-IV-TR.
Sunday, March 25, 2012
Autism and Aggressive Behavior
Autism is a category of disability that is often associated with aggressive behaviors. In working with individuals with autism, my experience has been that while most students with autism do not display aggressive behavior in school settings, there is a subset of students who will exhibit aggressive behaviors at some point in their school careers. This is usually early in their school experience, but may occur at any time at any time.
From a behaviorist standpoint, aggressive behavior (like all behavior) can be considered communicative in nature. The aggressive behavior communicates an unmet need when the student cannot communicate the need in a more pro-social manner. For example, a nonverbal student with autism may become aggressive because the task he is asked to do is non-preferred and he is unable to communicate that he does not want to do it in another manner that results in him discontinuing the task. In this situation the student has a need (i.e. to escape the task at hand) and a behavior (i.e. aggression) that is reinforced when the underlying need is met (i.e. when the aggression is sufficient that the student is allowed to discontinue the task. When intervening with a problem behavior such as this, a replacement method of communication of the student's need would be identified, taught, and reinforced. The problem behavior (aggression) would concurrently be placed on extinction (i.e. reinforcement is withheld) by attempting to limit it's ability to successfully result in escape from the the task. Common extinction strategies include planned ignoring, although this strategy may be difficult to apply with aggression due to safety concerns of the student, peers, and staff. The overall strategy is to find method of communicating the need that is pro-social and effective and then reinforce its use until it replaces the problem behavior because it is more effective for the student. Problem behaviors are then put on extinction to make them less effective while the pro-social (replacement) behavior is made more effective through reinforcement.
Students with autism often have a number of characteristics that place them at greater risk for adopting aggressive behaviors as a means of communicating one's needs. This is because individuals with autism have communication deficits and may have limited ability to make their needs know to others. They also have a predisposition toward sensitive nervous systems that may be impacted by a variety of factors in the environment (e.g. lighting, temperature, tactile sensations related to clothing/furniture/materials, etc.) These factors can lead to discomfort that may be difficult for the student to communicate to others. Because of social-interaction deficits, individuals with autism may have difficulty understanding the impact of aggression on others or interpreting social situations and individual behaviors in terms of the level of threat. Also, individuals with autism may not fully the perspective of others (* see previous blog on autism, section on Theory of Mind).
Aggression can be a learned behavioral response as well and some students with autism learn aggressive behaviors from peers or from educators or caregivers who have acted aggressively toward the student. Individuals with autism are at a higher risk for being mistreated by educators and/or caregivers due to communication deficits, repetitive stereotyped behaviors that can impact the behavior of others (e.g. repetitive hand flapping that becomes highly distracting to other students in a classroom), and social-interaction deficits. Once aggression has been modeled as an effective means of fulfilling a need, the student with autism may add it to his behavioral repretoir.
From a behaviorist standpoint, aggressive behavior (like all behavior) can be considered communicative in nature. The aggressive behavior communicates an unmet need when the student cannot communicate the need in a more pro-social manner. For example, a nonverbal student with autism may become aggressive because the task he is asked to do is non-preferred and he is unable to communicate that he does not want to do it in another manner that results in him discontinuing the task. In this situation the student has a need (i.e. to escape the task at hand) and a behavior (i.e. aggression) that is reinforced when the underlying need is met (i.e. when the aggression is sufficient that the student is allowed to discontinue the task. When intervening with a problem behavior such as this, a replacement method of communication of the student's need would be identified, taught, and reinforced. The problem behavior (aggression) would concurrently be placed on extinction (i.e. reinforcement is withheld) by attempting to limit it's ability to successfully result in escape from the the task. Common extinction strategies include planned ignoring, although this strategy may be difficult to apply with aggression due to safety concerns of the student, peers, and staff. The overall strategy is to find method of communicating the need that is pro-social and effective and then reinforce its use until it replaces the problem behavior because it is more effective for the student. Problem behaviors are then put on extinction to make them less effective while the pro-social (replacement) behavior is made more effective through reinforcement.
Students with autism often have a number of characteristics that place them at greater risk for adopting aggressive behaviors as a means of communicating one's needs. This is because individuals with autism have communication deficits and may have limited ability to make their needs know to others. They also have a predisposition toward sensitive nervous systems that may be impacted by a variety of factors in the environment (e.g. lighting, temperature, tactile sensations related to clothing/furniture/materials, etc.) These factors can lead to discomfort that may be difficult for the student to communicate to others. Because of social-interaction deficits, individuals with autism may have difficulty understanding the impact of aggression on others or interpreting social situations and individual behaviors in terms of the level of threat. Also, individuals with autism may not fully the perspective of others (* see previous blog on autism, section on Theory of Mind).
Aggression can be a learned behavioral response as well and some students with autism learn aggressive behaviors from peers or from educators or caregivers who have acted aggressively toward the student. Individuals with autism are at a higher risk for being mistreated by educators and/or caregivers due to communication deficits, repetitive stereotyped behaviors that can impact the behavior of others (e.g. repetitive hand flapping that becomes highly distracting to other students in a classroom), and social-interaction deficits. Once aggression has been modeled as an effective means of fulfilling a need, the student with autism may add it to his behavioral repretoir.
Saturday, March 24, 2012
Applied Behavior Analysis
The Behavior Analyst Certification Board (BACB) states on their website that the "field of Behavior Analysis grew out of the scientific study of
principles of learning and behavior. It has two main branches:
experimental and applied behavior analysis (ABA)." Applied behavior analysis uses the principles of learning and behavior established experimentally for the purpose of addressing behavioral needs in a variety of settings. The branch of applied behavior analysis has developed a rigorous process for establishing competency for practitioners. Professional organizations (e.g. IABA, Cal-ABA, etc.) and the BACB have helped establish general competencies for practitioner and a board certification (Board Certified Behavior Analyst) is available through the BACB. Board certification establishes that the individual has gone through a training process that included specific subject matter (including ethical practice), an internship under a BCBA, and subject area testing. A BCBA is considered competent to engage in behavior analysis activities such as conducting functional behavioral assessment (please refer to my previous blog page on functional assessment of behavior), consulting on problem behaviors in classroom and home environments, and designing interventions derived from applied behavior analysis.
When we talk about the general principles of behavior analysis established experimentally, we are speaking of principles like operant conditioning, which involves the modification of voluntary behaviors, maintained by consequences (i.e. a change that follows a response and changes the likelihood that it will occur in the future). In considering interventions, a behaviorist (e.g. BCBA, BCABA, autism specialist, teacher, etc.) may consider an intervention that reduces the likelihood of a problem behavior reoccurring and/or increases the likelihood of a replacement behavior occurring. Behavioral intervention then involves using reinforcement or punishment to increase or decrease the likelihood of a behavior reoccurring. To increase the likelihood of a behavior reoccurring, positive reinforcement or negative reinforcement can be used. Positive reinforcement refers to the provision of an appetitive (desired) stimulus to increase the likelihood that the behavior may occur in the future (e.g. verbal praise, stickers, or a high-five are provided to a student when they remember to raise their hand before asking a question). Negative reinforcement refers to the taking away of an aversive stimulus to increase the likelihood that
the behavior may occur in
the future (e.g. a weekly quiz given on Fridays is not required of students that turn all of their assignment for the week prior to the quiz). Positive punishment refers to the provision of a aversive stimulus to decrease the likelihood that
the behavior may occur in
the future (e.g. a student is sent to sit temporarily on a bench during recess due to arguing with another student). Negative punishment refers to the taking away of an appetitive stimulus to decrease the likelihood that
the behavior may occur in
the future (e.g. the minutes of allowed use of cell phone are decreased in response to excessive talking on the phone).
Friday, March 23, 2012
One to One Educational Assistants
One to one educational assistants are sometimes provided for students with severe difficulties (e.g. elopement, severe behavior/aggression, etc.). While one to one assistants can be highly successful interventions for some students, there are potential problems that may arise. First, students may become overly dependant on their one to one assistants. This can be prevented by having the one to one assistant encourage the student to function as independently as possible. It is also important that the student work with as many staff members in the classroom as possible to promote generalization. Since the mandate is to place all special education students in the least restrictive environment (LRE), the use of a one to one assistant may allow the student to be placed in their general education classroom. The use of the one to one assistant still, however, represents a restriction in itself that must be eventually faded to allow the student to function independently.
Desirable attributes in a one to one assistant include the ability to set appropriate boundaries, to respond calmly to stressful situations, and to demonstrate a respectful, caring, attitude with high expectations and an emphasis on positive reinforcement of desired behaviors. Furthermore, the one to one assistant should have sufficient training, especially if the student has a emergency behavior protocol that includes physical restraint as a last resort.
Thursday, March 22, 2012
Student Support Teams
A student support team (SST) is a group of school professionals that assemble at a meeting or series of meetings to address the specific academic and/or behavior needs of an individual student. These teams may also be referred to as student study teams, student success teams, or pre-referral teams, but all serve the same essential function. These teams are a function of the general education program within an individual school and are designed to bring parents and school professionals together to develop specific interventions within the general education setting. When a child has an academic and/or behavioral difficulty in the general education classroom, interventions are first developed by the child's individual teacher as part of the differentiation of instruction that all teachers are expected to provide within the general education classroom setting. If the teacher needs additional assistance, a referral is made to the SST and a meeting is scheduled. The typical members invited to a SST are the parent, the classroom teacher, an administrator (principal or vice-principal), as well as a number of potential additional members. Additional members that may be present include the school psychologist, school counselor, special education teacher, speech and language pathologist, autism specialist, occupational specialist, physical therapist, school nurse, or other persons who may make relevant contributions.
The general process for a SST begins with the teacher filling out a form to request an SST. The teacher will generally identify the current academic and behavioral functioning of the student, the problem/s of concern, and any interventions that have been tried. An SST is then scheduled on a date when the parent can attend. Most schools have an regularly scheduled SST meeting every week or every other week.
At the initial SST meeting, the team would get together and follow a process that may typically look like the following:
Introductions are made and the facilitator of the meeting will generally begin by asking about the students areas of strength and the things they enjoy doing. This helps orient the meeting in a positive manner, but more importantly it develops a pool of strengths that can be used in the process of building interventions. The problem/s areas and any other weaknesses of concern are then considered. Finally, one of three outcomes may occur. First, the SST may determine that the problem/s have been addressed with existing interventions or may be addressed with informal interventions that don't require significant follow-up. Second, the SST may develop interventions and data collection to address the problem with a follow-up meeting scheduled to review the progress. Third, in rare cases a student may be in need of immediate assessment for potential special education services due to severe academic or behavioral needs that require the implementation of interventions concurrently with assessment (e.g. when a student has a significant social-emotional concern that a delay in assessment would place the student and/or others at-risk). It is important to note that typically, a student would go through the process of an SST intervention with data collection with a six to eight week follow-up meeting to review the intervention results before assessment for special education would begin. The reason for this is that the initial intervention is to determine that the student's difficulties cannot be met within the regular educational environment with reasonable accommodations/support. This later becomes important in determining eligibility for special education services. The rationale behind this is that special education services are reserved for persons with identified disabilities as defined in federal law and state educational code whose needs cannot be met with reasonable modifications and accommodations to the general education environment. The key concept is that special education is designed to ensure that students with disabilities are able to access the general curriculum. If a student can access the curriculum with interventions in the general education environment, they are determined not to need special education services. To the extent that students with disabilities are not able to access the curriculum, the school district offers what is termed a free and appropriate public education (FAPE).
Ultimately, the SST is a team designed to bring together the people who best know the student (e.g. the parent, the teacher, other school personnel, etc.) to engage in a collaborative process that develops interventions that will hopefully address the student's problem within the existing educational environment. The reason for this is that research supports the premise that interventions are most successful when provided in the natural environments in which they exist. This is because it eliminates a step of generalization from another environment to the natural environment.
The general process for a SST begins with the teacher filling out a form to request an SST. The teacher will generally identify the current academic and behavioral functioning of the student, the problem/s of concern, and any interventions that have been tried. An SST is then scheduled on a date when the parent can attend. Most schools have an regularly scheduled SST meeting every week or every other week.
At the initial SST meeting, the team would get together and follow a process that may typically look like the following:
Introductions are made and the facilitator of the meeting will generally begin by asking about the students areas of strength and the things they enjoy doing. This helps orient the meeting in a positive manner, but more importantly it develops a pool of strengths that can be used in the process of building interventions. The problem/s areas and any other weaknesses of concern are then considered. Finally, one of three outcomes may occur. First, the SST may determine that the problem/s have been addressed with existing interventions or may be addressed with informal interventions that don't require significant follow-up. Second, the SST may develop interventions and data collection to address the problem with a follow-up meeting scheduled to review the progress. Third, in rare cases a student may be in need of immediate assessment for potential special education services due to severe academic or behavioral needs that require the implementation of interventions concurrently with assessment (e.g. when a student has a significant social-emotional concern that a delay in assessment would place the student and/or others at-risk). It is important to note that typically, a student would go through the process of an SST intervention with data collection with a six to eight week follow-up meeting to review the intervention results before assessment for special education would begin. The reason for this is that the initial intervention is to determine that the student's difficulties cannot be met within the regular educational environment with reasonable accommodations/support. This later becomes important in determining eligibility for special education services. The rationale behind this is that special education services are reserved for persons with identified disabilities as defined in federal law and state educational code whose needs cannot be met with reasonable modifications and accommodations to the general education environment. The key concept is that special education is designed to ensure that students with disabilities are able to access the general curriculum. If a student can access the curriculum with interventions in the general education environment, they are determined not to need special education services. To the extent that students with disabilities are not able to access the curriculum, the school district offers what is termed a free and appropriate public education (FAPE).
Ultimately, the SST is a team designed to bring together the people who best know the student (e.g. the parent, the teacher, other school personnel, etc.) to engage in a collaborative process that develops interventions that will hopefully address the student's problem within the existing educational environment. The reason for this is that research supports the premise that interventions are most successful when provided in the natural environments in which they exist. This is because it eliminates a step of generalization from another environment to the natural environment.
Tuesday, March 20, 2012
Functional Assessment of Behavior
A functional assessment of behavior (FBA) refers to assessment of problem behavior for purposes of determining the underlying function that the behavior serves for the individual. The Positive Environments, Network of Trainers website defines an FBA as an examination of antecedents to the problem behavior
and the consequences that occur following the behavior. A hypothesis is
then formed about what outcome the student gains by using this problem
behavior. They define behavior functions as consisting of either:
An FBA (or in California an Functional Analysis Assessment [FAA]) may be part of assessment conducted for addressing behavioral difficulties of students receiving special education services.
- Getting something desired (This behavior is working, or has worked in the past, to gain something. In other words, the behavior maintains because it is "positively reinforced."), or
- Protesting, Escaping or Avoiding something undesired (This behavior is working, or has worked in the past, to remove, partially remove, or communicate displeasure about something undesired by the student. In other words, the behavior maintains because it is "negatively reinforced.")
An FBA (or in California an Functional Analysis Assessment [FAA]) may be part of assessment conducted for addressing behavioral difficulties of students receiving special education services.
Monday, March 19, 2012
Feedback
After 24 hours as a blog and over two hundred visitors, I feel it is time to ask for some initial feedback to better support parents of exceptional children. Please take the time if you are able to let me know what topics you would like to see covered or to ask questions more specific to the needs of your own child. Thank you to those who have visited the blog so far. I look forward to collaborating with readers in development of a useful and objective resource for parents, caregivers, and others who seek to help exceptional children achieve happy, healthy lives.
Autism
I have worked with many individuals with autism over the past 16 years working as a special education teacher and school psychologist. Of all the individuals I've worked with over the years, it has been the children with autism that have most impacted my view of the world and brought my the most joy. People who speak a second language know that a person's reality is shaped by the language that they speak. The words and grammar give a structure that leads to a common understanding of the world. In that same sense, the neurological differences of individuals with autism lead them to experience and interact with the world in a manner that is highly different than individuals without autism. Through my work with individuals with autism I have come to fully understand the relative nature of reality and that my own reality is limited by my own cognition and communication. Through that realization I have come to the conclusion that it is crucial to acknowledge and accept the manner in which each individual experiences their reality before I determine what help they need and what to do to help them. I also realize the value of such diverse realities in helping us all develop a commonly accepted reality that reflects the richness of all our varied perspectives.
The complexities of autism make it difficult to know where to begin, but some brief background on the disorder is helpful in understanding our understanding of the disorder at present and development of treatments and interventions.
Background:
While many would begin by describing Leo Kanner's work with individuals with autism in the 1950s, I will begin at the point in which our modern definition of autism was developed. Wing and Gould (1979) have been credited with developing a definition of autism that is characterized by a triad of deficits in communication, deficits in social interaction, and repetitive stereotyped behaviors. This research led to the initial American Psychiatric Association's1980 DSM-III definition of autism that serves as the standard for medical diagnoses of autism. The current DSM-IV-TR places autistic disorder under the umbrella of autism spectrum disorders along with Asperger's disorder, pervasive developmental disorder not otherwise specified (NOS), Rett's disorder, and childhood disintigrative disorder. The triad of communication deficits, social interaction deficits, and repetitive stereotyped behaviors are important to our understanding of what autism is and how it impacts individuals with the disorder.
Early indicators of potential autism:
Early indicators of potential autism that parents might observe may include such behaviors as colic, arching of the back, delays in speaking first words and/or sentences, failure to acquire joint attention, sensitivity to textures/clothing/noise, obsession with parts of objects, repeatedly spinning and twirling body or objects, hand flapping, difficulty maintaining eye contact, obsessions/playing with water/edges/lights, failure to develop the ability to engage in cooperative play, obsession with sniffing/smelling people or objects, impulsivity, difficulties with attention, difficulties with transition, and unpredictable and/or explosive behavior. Any combination of these behaviors or additional behaviors not listed may be present. The key to understanding your child's behavior may be an indicator of autism is to consider the behaviors in the context of the overall definition of autism. Do the behaviors indicate concerns in the areas of communication, social-interaction, and repetitive stereotyped behavior. For example, both an individual with autism and an individual with apraxia have difficulties with communication, but the individual with autism will also concurrent deficits in social interaction and repetitive stereotyped behaviors. Also, delays should be considered in relation to overall development.
Cognitive Theories Related to Autism:
The cognitive impact of autism is highly individual, but some general theories have been proposed to describe the impact of the disorder on cognitive functioning. Researchers such as Uta Frith and Simon Baron-Cohen has proposed that individuals with autism lack a "Theory of Mind". Theory of Mind is the ability to attribute mental states—beliefs, intents, desires, pretending, knowledge, etc.—to oneself and others and to understand that others have beliefs, desires and intentions that are different from one's own. They propose that individuals with autism have a difficult time understanding the perspective of others. This has been experimentally measured using the "Sally-Anne Test". In this experiment, a child is given a doll named Sally-Anne who has a basket with an object inside. The experimenter opens the basket so that the child, the experimenter, and the doll can see that there is an object inside. The doll is then taken away, but the basket is left behind. The experimenter then removes the object from the basket while the child observes. Finally, the experimenter brings the doll back and asks the child what Sally Anne thinks is in the basket. Children with a Theory of Mind will state that Sally Anne thinks the object is still in the basket because she was not present to see it removed. Children with autism, however, will state that Sally Anne thinks the basket is empty because they assume that Sally Anne's perspective and belief is the same as their own.
"Weak Central Coherence Theory" is another cognitive theory advanced by Uta Frith. The premise of this theory is that individuals with autism have a tendency to gravitate toward the analytic (division into elements) and away from the gestalt (concept of wholeness). Difficulty grasping the gestalt of a given social situation or the gestalt of the combination of the various pieces of a facial expression (e.g. difficulty differentiating between a happy facial expression and an angry facial expression that may have different positions for the lips and mouth, but have little observable change in the eyes or other parts of the face.) Evidence for this cognitive preference has been asserted via the demonstrated strength demonstrated by individuals with autism on the Embedded Figures Test. A preference toward the analytic fits with some behaviors observed with autism such as spinning the wheels on a toy car rather than playing with a toy car in an imaginative manner, difficulty reading facial expressions, and difficulty understanding social situations.
The cognitive theory of an "Executive System" refers to higher level cognitive processes such as planning, organizing, initiating, inhibiting, working memory, attention, etc. It has been proposed that individuals with autism have deficit in executive functioning. These deficits fit with many behaviors we see exhibited by individuals with autism. For example difficulties with transition can represent a difficulty either initiating a behavior or inhibiting a behavior.
When considering the cognitive processes of an individual with autism it is more useful to think of theories like these in terms of their relationships to each other and in terms of the overall cognitive approach to a given task of an individual with autism. In consideration of these theories and our experience with behaviors related to autism we can could describe a cognitive approach to a given task as follows:
Example: A child with autism is attempting to understand the social expectations of a game of Uno with three peers at a small table. The child may be having difficulty with taking turns due to problems inhibiting the response placing a card (Executive Functioning Deficit). The difficulty taking turns may also be due an inability of the child to understand the beliefs/desires of others and therefore unable to understand why peers would not want him to play a card when the child wants to (Theory of Mind). Another possible explanation would be that the child cannot understand to whole concept of playing a game and the relationship between taking turns and making the game progress (Weak Central Coherence Theory).
Assessment of Individuals with Autism:
Assessment of individuals with autism often occurs initially before enrollment in kindergarten, but may potentially occur at any time during childhood. An initial assessment may be made by the child's pediatrician, neurologist, psychiatrist, clinical psychologist/LCSW/Psychiatric Nurse Practitioner, school psychologist, or autism specialist through the healthcare system or education system. Like all assessments of mental health disorders, there is no single method for conducting the assessment. Individuals in the healthcare system use the DSM-IV-TR definition of autism to guide their assessment and engage in a process of differential diagnosis to establish the diagnosis. In the educational system, the federal definition of autism (adapted at the state level) drives the process of identification of eligibility and a diagnosis is not made. In all cases, the breadth and depth of an assessment varies between practitioners. It has been my experience over the years that there is no one type of practitioner that produces consistently better assessments.
A typical assessment should begin with the collection of background information, including a developmental and medical history. Existing records, assessments, and other data will also be reviewed and relevant information included in the assessment. Often times, this will include structured interviews for gathering indirect assessment data or completion of behavioral assessment questionnaires. The child will also be observed in natural environments and across settings. Direct assessment may also be used in which the child will directly participate in testing activities with the examiner. Information will be gathered across all areas of development, with a focus on the child's functioning in the areas of communication and social-emotional functioning. Once the information has been gathered, the examiner will interpret the results and generate a report to share with you. In the healthcare system, the examiner will provide a diagnosis to you. In the educational system, a team of individuals will meet with you to review the results and determine as a team (with your input) as to whether your child is eligible to receive special education services. If the child is eligible, you will be then made an offer of Free and Appropriate Public Education in the form of an Individual Education Program (IEP) that you will be given the opportunity to accept or reject.
Interventions:
A number of interventions are available for addressing deficit skill areas and the behaviors associated with autism. They can be broadly categorized into medical, psychological, educational, and alternative/other interventions. Under medical interventions, we find pharmacological (medicine) interventions, occupational therapies, and dietary and supplemental intervention guided by a medical professional. Under psychological interventions, behaviorism is the primary theoretical construct under which interventions are generated. Under educational interventions, we find a broad range of interventions based on varying degrees to a broad range of psychological theories. Again, however, most of the educational interventions draw primarily upon aspects of behaviorism.
When considering interventions it is important for parents to think about the individual needs of their child as based on objective assessment data. Once an area of need has been recognized, an intervention can be developed that best meets the child's individual needs. While most people tend to discuss interventions for autism at the program level (e.g. TEACCH, ABA programs, etc.), I feel it is more important to understand interventions in terms of their theoretical foundations. No one program or approach is superior in all cases and drawing interventions from different theoretical foundations is necessary to optimize interventions between different students, as well as interventions particular to a individual student.
Areas of controversy:
The etiology (cause/s) of autism has not yet been conclusively determined. In recent years there has been concern regarding vaccines being a potential cause of autism. Current research indicates that no relationship can be established between vaccines and autism. The original research that indicated a correlation between vaccines and autism was published in the premier British Medical Journal, The Lancet. This research was later found to be fraudulent and retracted from the Lancet. Unfortunately, by the time this was fully addressed it had been spread by the media as a potential cause to the extent that it became taken as fact. This is part of the unfortunate process that can occur when the media reports research that has not been replicated and/or is correlational, but lacks an explanation of a viable mechanism of causality. Regarding the etiology of autism, there is research to support the hypothesis that it is likely that a combination of genes predisposes one to develop autism and some type of environmental insult during the gestational period (possibly during the first 14 to 20 months of development) triggers the disorder. This results in changes in brain development that lead to the deficits of executive functioning, communication, social interaction, and the repetitive stereotyped behaviors. The environmental insult may be viral in nature or perhaps a toxin of some sort. Should this be the case, it would certainly impossible to continue to argue that vaccines are responsible for autism. This continued belief that vaccinations cause autism is probably maintained at least partially by the fact that some of the the first signs we notice regarding autism surround the delays in language development and social-interaction deficits that become evident at around age 24 to 36 months, at about the same time that vaccines are given. While it is easy to assume that to things are linked when they occur closely together in time, without a reasonable explanation of the mechanism involved or congruence with our existing knowledge about autism we are left with a theory that is based on nothing more than coincidence. That is simply insufficient for scientific purposes and we must bring more rigor to our study of autism if we are going to ever fully understand its causes and develop more effective treatment options.
The complexities of autism make it difficult to know where to begin, but some brief background on the disorder is helpful in understanding our understanding of the disorder at present and development of treatments and interventions.
Background:
While many would begin by describing Leo Kanner's work with individuals with autism in the 1950s, I will begin at the point in which our modern definition of autism was developed. Wing and Gould (1979) have been credited with developing a definition of autism that is characterized by a triad of deficits in communication, deficits in social interaction, and repetitive stereotyped behaviors. This research led to the initial American Psychiatric Association's1980 DSM-III definition of autism that serves as the standard for medical diagnoses of autism. The current DSM-IV-TR places autistic disorder under the umbrella of autism spectrum disorders along with Asperger's disorder, pervasive developmental disorder not otherwise specified (NOS), Rett's disorder, and childhood disintigrative disorder. The triad of communication deficits, social interaction deficits, and repetitive stereotyped behaviors are important to our understanding of what autism is and how it impacts individuals with the disorder.
Early indicators of potential autism:
Early indicators of potential autism that parents might observe may include such behaviors as colic, arching of the back, delays in speaking first words and/or sentences, failure to acquire joint attention, sensitivity to textures/clothing/noise, obsession with parts of objects, repeatedly spinning and twirling body or objects, hand flapping, difficulty maintaining eye contact, obsessions/playing with water/edges/lights, failure to develop the ability to engage in cooperative play, obsession with sniffing/smelling people or objects, impulsivity, difficulties with attention, difficulties with transition, and unpredictable and/or explosive behavior. Any combination of these behaviors or additional behaviors not listed may be present. The key to understanding your child's behavior may be an indicator of autism is to consider the behaviors in the context of the overall definition of autism. Do the behaviors indicate concerns in the areas of communication, social-interaction, and repetitive stereotyped behavior. For example, both an individual with autism and an individual with apraxia have difficulties with communication, but the individual with autism will also concurrent deficits in social interaction and repetitive stereotyped behaviors. Also, delays should be considered in relation to overall development.
Cognitive Theories Related to Autism:
The cognitive impact of autism is highly individual, but some general theories have been proposed to describe the impact of the disorder on cognitive functioning. Researchers such as Uta Frith and Simon Baron-Cohen has proposed that individuals with autism lack a "Theory of Mind". Theory of Mind is the ability to attribute mental states—beliefs, intents, desires, pretending, knowledge, etc.—to oneself and others and to understand that others have beliefs, desires and intentions that are different from one's own. They propose that individuals with autism have a difficult time understanding the perspective of others. This has been experimentally measured using the "Sally-Anne Test". In this experiment, a child is given a doll named Sally-Anne who has a basket with an object inside. The experimenter opens the basket so that the child, the experimenter, and the doll can see that there is an object inside. The doll is then taken away, but the basket is left behind. The experimenter then removes the object from the basket while the child observes. Finally, the experimenter brings the doll back and asks the child what Sally Anne thinks is in the basket. Children with a Theory of Mind will state that Sally Anne thinks the object is still in the basket because she was not present to see it removed. Children with autism, however, will state that Sally Anne thinks the basket is empty because they assume that Sally Anne's perspective and belief is the same as their own.
"Weak Central Coherence Theory" is another cognitive theory advanced by Uta Frith. The premise of this theory is that individuals with autism have a tendency to gravitate toward the analytic (division into elements) and away from the gestalt (concept of wholeness). Difficulty grasping the gestalt of a given social situation or the gestalt of the combination of the various pieces of a facial expression (e.g. difficulty differentiating between a happy facial expression and an angry facial expression that may have different positions for the lips and mouth, but have little observable change in the eyes or other parts of the face.) Evidence for this cognitive preference has been asserted via the demonstrated strength demonstrated by individuals with autism on the Embedded Figures Test. A preference toward the analytic fits with some behaviors observed with autism such as spinning the wheels on a toy car rather than playing with a toy car in an imaginative manner, difficulty reading facial expressions, and difficulty understanding social situations.
The cognitive theory of an "Executive System" refers to higher level cognitive processes such as planning, organizing, initiating, inhibiting, working memory, attention, etc. It has been proposed that individuals with autism have deficit in executive functioning. These deficits fit with many behaviors we see exhibited by individuals with autism. For example difficulties with transition can represent a difficulty either initiating a behavior or inhibiting a behavior.
When considering the cognitive processes of an individual with autism it is more useful to think of theories like these in terms of their relationships to each other and in terms of the overall cognitive approach to a given task of an individual with autism. In consideration of these theories and our experience with behaviors related to autism we can could describe a cognitive approach to a given task as follows:
Example: A child with autism is attempting to understand the social expectations of a game of Uno with three peers at a small table. The child may be having difficulty with taking turns due to problems inhibiting the response placing a card (Executive Functioning Deficit). The difficulty taking turns may also be due an inability of the child to understand the beliefs/desires of others and therefore unable to understand why peers would not want him to play a card when the child wants to (Theory of Mind). Another possible explanation would be that the child cannot understand to whole concept of playing a game and the relationship between taking turns and making the game progress (Weak Central Coherence Theory).
Assessment of Individuals with Autism:
Assessment of individuals with autism often occurs initially before enrollment in kindergarten, but may potentially occur at any time during childhood. An initial assessment may be made by the child's pediatrician, neurologist, psychiatrist, clinical psychologist/LCSW/Psychiatric Nurse Practitioner, school psychologist, or autism specialist through the healthcare system or education system. Like all assessments of mental health disorders, there is no single method for conducting the assessment. Individuals in the healthcare system use the DSM-IV-TR definition of autism to guide their assessment and engage in a process of differential diagnosis to establish the diagnosis. In the educational system, the federal definition of autism (adapted at the state level) drives the process of identification of eligibility and a diagnosis is not made. In all cases, the breadth and depth of an assessment varies between practitioners. It has been my experience over the years that there is no one type of practitioner that produces consistently better assessments.
A typical assessment should begin with the collection of background information, including a developmental and medical history. Existing records, assessments, and other data will also be reviewed and relevant information included in the assessment. Often times, this will include structured interviews for gathering indirect assessment data or completion of behavioral assessment questionnaires. The child will also be observed in natural environments and across settings. Direct assessment may also be used in which the child will directly participate in testing activities with the examiner. Information will be gathered across all areas of development, with a focus on the child's functioning in the areas of communication and social-emotional functioning. Once the information has been gathered, the examiner will interpret the results and generate a report to share with you. In the healthcare system, the examiner will provide a diagnosis to you. In the educational system, a team of individuals will meet with you to review the results and determine as a team (with your input) as to whether your child is eligible to receive special education services. If the child is eligible, you will be then made an offer of Free and Appropriate Public Education in the form of an Individual Education Program (IEP) that you will be given the opportunity to accept or reject.
Interventions:
A number of interventions are available for addressing deficit skill areas and the behaviors associated with autism. They can be broadly categorized into medical, psychological, educational, and alternative/other interventions. Under medical interventions, we find pharmacological (medicine) interventions, occupational therapies, and dietary and supplemental intervention guided by a medical professional. Under psychological interventions, behaviorism is the primary theoretical construct under which interventions are generated. Under educational interventions, we find a broad range of interventions based on varying degrees to a broad range of psychological theories. Again, however, most of the educational interventions draw primarily upon aspects of behaviorism.
When considering interventions it is important for parents to think about the individual needs of their child as based on objective assessment data. Once an area of need has been recognized, an intervention can be developed that best meets the child's individual needs. While most people tend to discuss interventions for autism at the program level (e.g. TEACCH, ABA programs, etc.), I feel it is more important to understand interventions in terms of their theoretical foundations. No one program or approach is superior in all cases and drawing interventions from different theoretical foundations is necessary to optimize interventions between different students, as well as interventions particular to a individual student.
Areas of controversy:
The etiology (cause/s) of autism has not yet been conclusively determined. In recent years there has been concern regarding vaccines being a potential cause of autism. Current research indicates that no relationship can be established between vaccines and autism. The original research that indicated a correlation between vaccines and autism was published in the premier British Medical Journal, The Lancet. This research was later found to be fraudulent and retracted from the Lancet. Unfortunately, by the time this was fully addressed it had been spread by the media as a potential cause to the extent that it became taken as fact. This is part of the unfortunate process that can occur when the media reports research that has not been replicated and/or is correlational, but lacks an explanation of a viable mechanism of causality. Regarding the etiology of autism, there is research to support the hypothesis that it is likely that a combination of genes predisposes one to develop autism and some type of environmental insult during the gestational period (possibly during the first 14 to 20 months of development) triggers the disorder. This results in changes in brain development that lead to the deficits of executive functioning, communication, social interaction, and the repetitive stereotyped behaviors. The environmental insult may be viral in nature or perhaps a toxin of some sort. Should this be the case, it would certainly impossible to continue to argue that vaccines are responsible for autism. This continued belief that vaccinations cause autism is probably maintained at least partially by the fact that some of the the first signs we notice regarding autism surround the delays in language development and social-interaction deficits that become evident at around age 24 to 36 months, at about the same time that vaccines are given. While it is easy to assume that to things are linked when they occur closely together in time, without a reasonable explanation of the mechanism involved or congruence with our existing knowledge about autism we are left with a theory that is based on nothing more than coincidence. That is simply insufficient for scientific purposes and we must bring more rigor to our study of autism if we are going to ever fully understand its causes and develop more effective treatment options.
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