Special Education Needs and Autism

MA in Special Education Needs Liverpool John Moores University Understanding Autism Vasileios Evangelidis 23rd of January 2012 “Early infantile autism”  Kanner (1943) described autism as extreme aloneness, insistence on sameness, obsessiveness, followed by stereotypies and echolalia, altogether with islets of skills.  He named this unusual pattern of behaviour “early infantile autism”.  Crucial for the diagnosis were the profound lack of emotional contact, the insistence on bizarre and elaborate repetitive routines, muteness or marked abnormalities of speech, fascination in manipulating objects, etc. (Wing, 2002). “Autistic psychopathy”  Asperger (1944) contrasted autism from schizophrenia by emphasizing the stable and enduring nature of the social impairments and by voicing the optimistic view that unlike schizophrenia, his patients were able to develop relations.  They exhibited naive, inappropriate social approaches, intense circumscribed interest in particular subjects as railway timetables; monotonous speech, specific learning difficulties in one or two subjects, and a marked lack of common sense (Wing, 2002; Klin, McPartland, Volkmar, 2005). 3 areas of deficit in Autism 1. Social Impairment: Lack of response to other person’s voice, absence of pointing, failure to understand gesture. Failure to greet, lack of initiative in directing visual attention. 2. Language Impairment: Children with autism exhibit delayed and/or impaired language development and persistent abnormalities of pragmatic language, e.g. in conversation, understanding jokes, figurative expressions, and inferencing. 3. Restricted, repetitive behaviour and Obsessions: Stereotypic hand and finger movements and unusual sensory behaviour. The “triad” of impairments Wing (2002) has given an alternative categorization of the core autistic features:  Social interaction: The four main types of autistics are categorized as the aloof group, the passive group, the active but odd group, and the over-formal, stilted group.  Communication: Muteness, delayed speech, echolalia, delayed echolalia, poor understanding, odd intonation, etc.  Imagination: Lack of pretend play. The impairment of creative, flexible imagination leads to repetitive stereotyped activities (finger flicking, head rolling, flapping arms, etc.). Assessment  A health visitor or a doctor can decide whether a detailed assessment would be helpful. Special assessment can be made by a paediatrician, a child clinical psychologist, a child psychiatrist, a speech therapist for a language and communication assessment, and a child development team.  Symptoms of social disability become more apparent around 12 months of age. Behaviors at this age include responsivity to name, atypical object exploration and repetitive behaviors, and language communication (Steiner et al. 2011). and nonverbal Types of Assessment  Play based direct assessment; Parent interview; Parent rating form; Parent, teacher and caregiver rating forms.  Structured activities, observation, and parent/caregiver interview. Parent questionnaire; Parent report inventory of words and gestures (Steiner et al. 2011).  Phonetic Test in Greek Language; CELF; Action Picture Test; TROG; Word Finding Vocabulary Test; Bus Story Test; Test of Pragmatic Language; Symbolic Play Test (Vogindroukas, Sherratt, 2005). PEP; CARS (Chitoglou-Antoniadou, Kekes, ChitoglouChatzi, 2000). Early signs of ASD  In the first 6 months, babies with ASD rarely look at their parents faces or eyes, or do little babbling or imitating of their parents movements or sounds.  At 6 to 12 months, some babies with ASD do not crawl or move about, don’t stand with support, or can’t say little words or can’t use simple gestures (e.g. “bye bye”).  At 18 months, some children with ASD fail to use two words together with meaning.  Sometimes they tend to gain and then appear to lose language skills. Symptoms by the age of 3 years  In more severe cases of autism the child may be very much in a world of his own most of the time, and may seem to treat people as if they were objects.  Causes for concern at 3 to 5 years (apart from poor eye contact and little interest with other people or pretend play), may be lonely playing, ignoring or laughing at relations, being puzzled by the imaginative play of other children.  Not interested in joining in group games, wandering around.  Very little language, or repetitive or verbose language; Repeating phrases from films, TV, etc.; Echolalia. Symptoms by the age of 6 years  Poor eye contact. Unlikely to use readily gestures such as pointing, beckoning, waving or making a “shhh” gesture with their finger to mean “be quiet”.  Without close friends of the same age.  Not pursuing or enjoying pretend play with other children.  Fascinated by a topic which takes up large amounts of time and may seem slightly unusual, e.g. counting the different colours of the cars on the road.  Flapping his hands or making odd movements when upset or excited (Williams, Wright, 2004). Symptoms in adolescence  In most cases, problems on the autism spectrum are detected before adolescence. ASD does not suddenly develop at this age.  Causes for concern at 12 to 17 years are flat or unusual facial expressions; difficulty making and keeping friends.  Poor eye contact, poor understanding, misjudging.  Exhibiting socially inappropriate behaviour.  They also have notable deficits in prosody, associated more with pragmatic and affective processes than with deficits in the grammatical functions of prosody. The social aspect of autism  Social inefficiency, reduced ability for learning, handicapped behaviour.  Insufficient understanding of basic social signals, e.g. facial expressions, gestures, body positions.  Inability for empathy. Difficulty to treat other children in accordance with a “theory of mind”, i.e. not understanding that all persons have different ideas, thoughts and desires.  Many children have difficulty to pass from imitation to action, without guidance. The emotional aspect of autism  The children with autism have difficulties with the meaning of friendship. They look indifferent, frigid, aloof, remote.  They also have difficulties in understanding notions related to emotions. They perceive emotions misrepresented.  ASD children differ in Affect Regulation, i.e. to the extrinsic and intrinsic processes for monitoring, evaluating, and modifying emotional reactions, to accomplish one’s goals.  They are more likely to show greater impulsivity, fear, discomfort and shyness. By contrast, they are lower in soothability, inhibitory control, attention focusing and shifting. The communicative aspect of autism  The 50% or more of the children with autism do not use at all speech. For this reason they have a basic problem in communication, especially with understanding.  Even children with high-functioning autism have problems in communication because of deficiency in executive function.  They seem to lack a sense of “self-consciousness”, of the “self-involvement”, the acting with, and the identification with the acting person.  They also lack of varied, spontaneous make-believe play or social imitative play. Problems managing behaviour  Aggressiveness, self-injury, damage to property, stereotyped eruptions of anger. Severe temper tantrums (Wing, 2002).  Inappropriate and difficult behaviour may be caused by confusion and fear of unfamiliar situations.  Interference with repetitive routines; failure to understand social rules, etc. In the family home the children with autism may be restless, destructive, noisy, aggressive if frustrated, and given to running away.  Some autistic persons have also epilepsy since childhood (Danielsson et al. 2005). The linguistic aspect of autism  A characteristic element in the speech of many children with autism is the echolalia, the immediate, involuntary and stereotyped repetition of words just spoken by others.  Children with autism produce echolalia either directly (thus they hear something and immediately repeat it) or after a delay (e.g. after 3-4 days they may repeat a phrase they have heard in an advertisement).  Some children with autistic spectrum disorders produce echolalia by repeating songs or big texts, but they cannot answer a single question. Islets of savant skills  As Scheuffgen et al. (2000) argue, autism frequently presents savant skills, such as music, drawing, mnemonism, calendar calculation, jigsaw construction, memory for routes, etc.  Kanner (1943) emphasized that the speaking children with autism may have astounding vocabulary, excellent memory, and recollection abilities.  Playing musical instruments; performing lengthy numerical calculations; reading fluently though poor comprehension; memorizing; assembling constructional toys. Heredity  Scientists have observed a concordance for autism of about 60% to 90% in monozygotic twins.  They have also observed a concordance for autism of about 5% to 10% in dizygotic twins (Syriopoulou-Delli, 2011).  Heredity or genetic factors are responsible for the 90% of autism cases.  Similar results, from family research, show that the percentage of autistic siblings is about 2% to 7%, much higher than the percentage in general population (0,5%). Theory of Mind  Individuals with autism lack the capacity to have a theory of other people’s mental states, such as beliefs, desires and intentions.  Their ability to take the perspective of another person - to adequately evaluate other people’s interests, beliefs, intentions and feelings - is typically impaired in real life contexts.  This fundamental deficit may explain the triad of symptoms defining autism, namely, impairment of social communicative functioning and imaginative activities. and Mentalizing and predicting  First order theory of mind refers to situations in which a subject must attribute a mental state, such as a belief, to another person.  Second order theory of mind requires recursive thinking about mental states, in which a subject must predict one person’s thought about another person’s thoughts.  First order tasks begin to be mastered by age 4, whereas the ability to make second-order attributions develops at around the age of 7 (Klin, McPartland, Volkmar, 2005). Mindblindness  Baron-Cohen (1997b) argued that mindblindness is caused by impairments in shared attention and in theory of mind.  Although autistics are able to detect intentions (e.g. “want”) and eye-direction, they lack joint-attention behavior.  The impairment in shared attention can be early observed by the absence of the protodeclarative pointing gesture.  Theory of mind is triggered by shared attention, and is responsible for the understanding of the mental states of knowing, believing, pretending, distinguishing appearance from reality, etc. Joint Attention and Smile  The autistic children diverge much more markedly in their decreased level of positive feeling during situations of joint attention, where the typically developing children smile.  There are autism-specific abnormalities in face-to-face affective coordination, e.g. combining smiles with eye contact, smiling in response to mother’s smile, etc.  Smile, pointing gesture, gaze-monitoring, and showing gestures are absent in most children with autism.  Impaired facial mimicry of emotions in autism. Repetitive behaviour  The theory of mind account has been virtually silent on why children with autism should show “repetitive behaviour”, a strong desire for routines, and a “need for sameness”. To date, the only cognitive account to attempt to explain this aspects of the syndrome is the executive dysfunction theory, assuming that it is a form of ‘frontal lobe’ perseveration or inability to shift attention (Baron-Cohen, 1997a).  Children with autism tend to avoid certain sorrowful events by characteristic behaviours such as self-stimulation, echolalia and insistence on sameness (Syriopoulou-Delli, 2011). Executive function  Executive function is responsible for higher level action control, for maintaining a mentally specified goal and for implementing that goal in the face of distracting alternatives.  It includes inhibition, set shifting, planning, coordination and control of action sequences (Fisher, Happé, 2005).  Executive dysfunction occurs in both individuals with autism and their family members, across many ages and functioning levels. Inhibitory control and possibly working memory are relatively spared functions in autism, while mental flexibility is impaired (Ozonoff, South, Provencal, 2005). Flexibility and attention  Operations that require flexibility, such as the shifting of attention, are impaired in individuals with autism, while inhibitory functions appear relatively intact.  Flexibility on attention shifting tasks is correlated with social understanding tasks and adaptive behaviour.  Joint attention and flexibility in autism are much more impaired with social than nonsocial stimuli.  Against a general executive dysfunction in autistic individuals, is the fact that many of them have strengths in physics, mathematics and biology (Baron-Cohen,1997a). Possible associations between theory of mind and executive functions theory  Both theories often seem equally useful, e.g. comparing performance on joint attention and false beliefs tasks.  “Several explanations for this association have been proposed: (1) the deficits are independent modular cognitive operations that are parallel central impairments of autism, (2) one ability is a prerequisite for the other, so that deficits in one cause deficits in the other, (3) both are driven by a third shared impairment, or (4) both share similar neural underpinnings” (Ozonoff, South, Provencal, 2005, p. 613). Central Coherence  Children with autism may show good discrimination and categorization abilities, and yet poor generalization of learning.  They tend to be more accurate and faster in tests that require ignoring the global configuration and focusing on parts.  This theory attempts to explain not only impairments but also the islets of abilities, repeatedly found in autism.  The advantage of Central Coherence theory is that the cognitive profile of autism is unique: Difficulty integrating information in context, paired with superior processing of sensory information (López, 2008). local Alternative theories  The assumption that superior processing for parts is the result of impairment in the ability to integrate information (e.g. global processing) is questioned by López (2008).  Happé and Frith (2006) emphasized the idea of superiority in local processing rather than deficit in global processing.  People with autism may have enhanced discrimination of unique features and reduced generalization of common features (Plaisted, 2001).  Enhanced perceptual functioning theory states that autistic perceptual processing (Mottron et al. 2006). overrides higher-control processes Gestalt processing  Children with autism use fewer Gestalt principles, thus, they have difficulty to process the interconnections between the different parts in order to build the whole.  They appear to fail in utilising gestalt grouping principles (proximity, similarity, closure) and in identifying certain impossible figures (Brosnan et al. 2003).  Perceptual integration difficulty in autism; in tasks where the replacement of any element alters the perception of the whole and where it is necessary to process simultaneously the interconnections between all the elements. Comparison between theories  Theory of mind, attention shifting and handling symbols seem as the main domains impaired in autism.  There are other autistic symptoms (such as repetitive behaviour, and unusual perception) that are not easily explained by the theory of mind deficit.  The executive hypothesis of autism is important, since it explains the perseverative, repetitive behaviours.  The central coherence account of autism explains the non- holistic, fragmentary perceptual style characteristic of autism; and the unusual cognitive profile (including the islets of ability). Imitation, Play and Mirror Neurons  The linkage between imitation and symbolic play is developed by the mental representations of events that children experience and reproduce at a later time.  The autistic impairment in joint attention impedes the representative ability in symbolic play and imitation.  Difficulties in planning and executing an imitative movement may occur because of poor body awareness (kinesthesia).  Mirror neurons, in the superior temporal sulcus, are responsible for understanding imitation and intentionality. Pretend play  Both functional and sensorimotor play are accompanied with the sharing behaviour of joint attention, which may be viewed as a form of early dialogue.  Symbolic play consists of 3 important attitudes: object substitution, pretense, and dramatization (Gena et al. 2007).  Autistic children have difficulty with the decoupling mechanism, i.e. the ability to dissociate between the “true” meaning and the pretense in the context of play.  They fail in careful observation, imitation and interpretation of the ways in which others use and react with objects. Autistic Spectrum Disorders  The Autistic Spectrum Disorders are often categorized in a continuum from profound aloofness and mental retarding, to distinctive social or empathic blindness.  “Having autism as the paradigmatic and anchoring disorder in this diagnostic category” the Autistic Spectrum Disorders “more generally are characterized by marked and enduring impairments within the domains of social interaction, communication, play and imagination, and a restricted range of behaviors or interests” (Klin et al. 2005, p. 88). Asperger Syndrome  Asperger Syndrome is a severe and chronic developmental disorder closely related to autistic disorder and pervasive developmental disorder-not otherwise specified (PDD-NOS) and together these disorders comprise a continuum referred to as autistic spectrum disorders.  Asperger Syndrome is distinguished from autism primarily on the basis of a relative preservation of linguistic and positive capacities in the first 3 years of life.  Asperger Syndrome is autism without mental retardation, thus AS relates to higher functioning autism. Difficulties present in the first 2 years of life in Asperger Syndrome  Lack of normal interest and pleasure in other people.  Babbling that is limited in quality and quantity.  Reduced sharing of interests and activities.  Absence of an intense drive to communicate both verbally and non-verbally with others.  Speech that is abnormal in terms of delayed acquisition or impoverished content consisting mainly of stereotyped utterances.  Failure to develop a full repertoire of imaginative pretend play (Lorna Wing, 1981). The clinical concept of Asperger Syndrome  Individuals with higher verbal abilities or less disabled individuals.  Asperger Syndrome refers to “milder” forms of autism marked by higher cognitive and linguistic abilities.  More socially motivated but socially vulnerable adolescents and adults with unusual and interfering circumscribed interests.  Impairment in nonverbal communication. Reduction in the quantity and the diversity of facial expressions and limitations in the use of gesture, etc. Pervasive Developmental Disorder Not Otherwise Specified  A severe deficit in social learning and reciprocity, that is associated with impairments in either verbal or non-verbal communication.  Social deficits similar to autism. Possible fundamental disturbances in communication, social behaviour, emotion regulation, cognition, and interests.  Impairments in understanding affect regulation, affective modulation and patterns of attachment (Towbin, 2005). Rett Syndrome  Rett syndrome represents one of the most common causes of mental retardation, second only to Down Syndrome.  It almost exclusively affects females.  Stereotypic hand movements, typically at midline, are one of the most prominent symptoms.  Hand patting, waving, involuntary movements, such as alternate opening and closing of the fingers, twisting of the wrists and arms, nonspecific circulating hand-mouth movements appear to be warning signals (Van Acker et al. 2005).  Lack of sustained interest in persons, limited contact. Dementia infantilis  Childhood Disintegrative Disorder, Heller’s Syndrome, or disintegrative psychosis.  Theodore Heller (1908) termed this regression dementia infantilis.  A period of several years of normal development before a marked deterioration. Catastrophic loss of skills in at least two of the following areas: language; play; social skills; bowel or bladder control; motor skills (Wing, 2002).  Progressive deterioration either gradual or abrupt.  Behavioural and affective symptoms. Childhood Disintegrative Disorder  Absence of features of gross neurological dysfunction.  Social skills are markedly impaired.  Total muting or marked deterioration in verbal language.  Sparsity of communicative acts, limited expressive vocabulary and markedly impaired pragmatic skills.  Stereotyped behaviours, problems with transitions and change, nonspecific overactivity.  Deterioration in self-help skills, notably toileting.  The CDD cases are more likely to be mute, more likely to be in residential placement, and so forth (Volkmar et al. 2005). Other related disorders  Tuberose sclerosis, phenylketonuria, encephalitis, etc. can be associated with autistic behaviour.  Other related disorders are Fragile X syndrome, LandauKleffner syndrome, Williams syndrome, Cornelia de Lange syndrome, Tourette’s syndrome (Wing, 2002).  Many other diagnoses are related to autism: SemanticPragmatic Disorder, Non-Verbal Learning Disorder, Pathological Demand Avoidance Syndrome (Vogindroukas, Sherratt, 2005). Intervention  Milieu teaching is a naturalistic approach that promotes the acquisition of skills (e.g. social interaction) in the contexts where they are likely to be used (Gena et al. 2007).  Peer-mediated teaching is another naturalistic approach. Peers do not only serve as instructors, but may also serve as models for appropriate behaviour.  Direct instruction or discrete-trial teaching, systematic, structured, and rigorous approach. a very  Reciprocal imitation training, in vivo modeling and play scripts, video modeling. Parent training. Therapeutical applications  Applied Behaviour Analysis; Behaviourist learning program.  SPELL (Structure, Positive attitudes, Empathy, Low arousal, Links) developed in UK (NAS).  PECS (Picture Exchange Communication System).  TEACCH (Treatment and Education of Autistic and related Communication Handicapped Children).  MAKATON (combination of gestures and language).  Speech therapy (combinable with PECS); Daily Life Therapy (Higashi); Music Therapy; Sensory Integration Therapy; Vision Training; Berard Auditory Integration Training; Floor Time approach. Teaching tasks  Keeping eye contact and sharing attention; Empathy; Comprehending other persons’ emotions. Adjusting and processing the distance from others.  Waiting for their turn in group activities and play; Understanding other persons’ intentions and learning the relevant rules in any activity; Listing personal interests.  Rehabilitating the interpersonal relationships; Recognizing facial expressions. Understanding what other people think; Sharing interesting information; Translating body language (Vogindroukas, Sherratt, 2005).  Activities Learning activities oriented toward relationships and social conventions, e.g. role playing; Multisensory communication through objects, symbols, photos, etc.; Especially visual methods.  Support in play and creativity; Relating to others for entertainment; Playing and embedding representations; Unifying ideas; Encouraging narration and dialogue.  Following orders; Guiding others; Inferring and evaluating; Enigmas, puzzles, metaphors, anecdotes; vocabulary (Vogindroukas, Sherratt, 2005). 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