NJEA recently ran an article on autism in the May 2009 NJEA Review.
Autism is at once a fearful diagnosis for families and a challenge for educators. Yet, there are many myths and misunderstandings concerning both the diagnosis of Pervasive Developmental Disorders (PDD)/Autism Spectrum Disorders (ASD) and efficacious and sustainable therapeutic interventions. We have come a long way from blaming Autism on a lack of maternal nurturing–the discredited and so-called “refrigerator mother” theories popularized by Bruno Bettelheim in the 1950s and ’60s–to a scientifically grounded recognition that PDD/ASD are neurological disorders of early brain development.
The diagnosis of PDD/ASD is based upon a final common behavioral pathway of aberrancies defined in three behavioral domains: impairment of verbal and nonverbal communication, imagination and play; atypical sociability, lack of empathy or the ability to have insight into others’ view of the world (“Theory of Mind”); and restricted interests and activities associated with repetitive movements (“stereotypies”). These behavioral features are somewhat ubiquitous, subjective and non-specific, and can result from an array of underlying neurobiological mechanisms. Therefore, it is important to properly and accurately diagnose PDD/ASD, eliminating potential mimickers of this disorder (for example, hearing loss), so families are not unnecessarily traumatized and appropriate therapies and interventions can be implemented.
Possible causes of Autism
There have been concerns of an increasing incidence of PDD/ASD, with exclamations of a pandemic, particularly in New Jersey, where the prevalence of PDD/ASD has been cited to be one in every 94 children, compared to an average of one in 150 throughout the nation. Although the increase in the number of diagnoses can be partially explained by a number of factors–changes in diagnostic criteria; better recognition of the disorder at younger ages; inclusion of milder cases; migration to states providing better services–there appears to be a true overall rise in the incidence and prevalence of PDD/ASD. This has led to speculation that PDD/ASD can be caused by common childhood vaccinations or environmental toxins.
However, a vast array of scientific evidence has found no credible causal link between vaccinations and PDD/ASD, and removal from vaccines of the mercury preservative thimerosal, which has been blamed as a causative agent, has not precipitated any reductions in the incidence or prevalence of PDD/ASD. Unfortunately, the fear of vaccinations based on faulty hypotheses and theories has led to reductions in immunized children and a rise in deadly infectious diseases. There has also been no definitive link with any particular environmental toxin, although there are ongoing studies.
Evidence from genetic, neuroimaging, neuropathological, and neurophysiological studies have found that PDD/ASD are intrinsic neurobiological/neurogenetic disorders, possibly influenced by environmental triggers in some cases, resulting in impairment of early brain development and an “under-connectivity” and disorganization in crucial neural pathways and networks. PDD/ASD can be associated with a number of known genetic, neurometabolic and neurotransmitter disorders, and hormonal and immunological abnormalities can also be found in some children.
What are the clinical features of Autism?
In addition to behavioral abnormalities, the clinical features of PDD/ASD are important for educators and school professionals to understand and recognize. “Dyspraxia” is a common finding, which is a neurological difficulty in sequencing and planning, manifesting as poor coordination, articulation deficits or sensory defensiveness. Sensory and perceptual deficits are also common and can affect all sensory modalities. They are marked by an increased or decreased responsiveness to sensory stimuli.
Children with PDD/ASD may have significant sleep disturbances, which can exacerbate daytime behavioral difficulties or inattentiveness. Up to 40 percent will have Epilepsy, sometimes with subtle “absence” seizures that can be misdiagnosed as Attention Deficit/Hyperactivity Disorder (ADHD). Neurobehavioral disturbances include inattentiveness, impulsiveness, hyperactivity, anxiety, and in severe cases, self-injurious and aggressive behaviors.
It is important that the diagnosis of Autism be made as early as possible, as earlier therapeutic interventions afford better outcomes. However, care must be taken to avoid raising the anxiety and stress levels of families with zealous and over-inclusive labeling of children going through transient developmental phases or lags, or those who are creative and unique with pedantic language or social skill issues but are not truly autistic. Thus, it is important for educators and school professionals to be aware of the “red flags” of Autism, since difficulties may not be noticeable until arrival into a school program. There are also many screening tools that are available to identify children at risk for PDD/ASD. When there are concerns that a child may be manifesting symptoms or signs of PDD/ASD, it is incumbent that a referral be made to an appropriate professional or clinical center capable of performing accurate diagnostic assessments.
Early signs that should raise suspicions include impairments in verbal and nonverbal communication; a lack of reciprocal social interaction; poor representational or pretend play skills; or loss of language or play skills. For those interfacing with the 0-3 year groups, there should be immediate referral if there has been no babbling or pointing or other gestures by 12 months; no single words by 16 months; no two-word spontaneous (not echoing what others say) phrases by 24 months.
In older children and adolescents who have escaped identification in early years, even if there is a high level of intellectual functioning or academic performance, concerns should be raised for those who are socially isolated or manifest odd social mannerisms, display a lack of empathy, tend towards a very concrete interpretation of language, or have difficulties with conceptual learning (often excelling with factual learning).
Although receiving a diagnosis of Autism can be a devastating experience, there is much that can be done to assist a child to reach their full potential, and in some cases pave a road to recovery. The mainstay of treatment intervention is a steady, individualized and labor intensive behavioral and educational program, utilizing evidence-based approaches. Educators should assess a child’s response to interventions and adjust programming to affect a positive outcome. In some cases, adjunctive medical therapies are necessary to achieve success or to target underlying adverse medical or neurological problems or disorders. Thus, there needs to be a multimodal and multidisciplinary approach to children with PDD/ASD, utilizing the expertise and involvement of an array of professionals from the worlds of education, clinical medicine and psychology, and other therapeutic fields, as well as informed involvement and participation of families.
For effective services to be delivered, educators, clinicians, therapists and family members need to communicate, strategize and understand that there is a changing dynamic in the approaches to intervention programs for children with PDD/ASD. These changes involve migrating away from the “standard” intensive behavioral interventions (rigid applications of Applied Behavioral Analysis [ABA] for purposes of behavioral reduction) towards more dynamic “new look” intervention strategies that utilize and cultivate a child’s intrinsic abilities and skills in the context of a social environment.
Autistic conditions have been recognized to have a neurological, not psychogenic, origin for at least the past 50 years. During this time, remedial and educational intervention strategies have flourished, while most biologically-based treatments have fallen to the wayside. The current outcome literature supports empirically-based educational, social and communication interventions that can improve functioning, with biomedical interventions in an adjunctive role. Early intensive behavioral intervention models, while showing promise, have often resulted in unsustainable and poorly generalized outcomes. More recent innovations, while still evidence-based, are focused on creating more natural learning environments, communication tools, and social learning opportunities, combined with integration with appropriate peers. The hallmark characteristics of naturalistic learning and peer-mediated interventions have become identified with “The New Look” in Autism intervention approaches. An article elaborating on these methodologies, and the research basis for their efficacy, will be presented in the NJEA Review this fall.
Teachers play a crucial role in the successful outcome of children with PDD/ASD. Educators and school professionals are on the “front lines,” saddled with the responsibility for identification of those children warranting further evaluation and assessment, providing important empirical data and observations to other care providers that will affect clinical, behavioral and educational treatment interventions and programming.
Mark Mintz, M.D. and Daniel LeGoff, Ph.D. work at The Center for Neurological and Neurodevelopmental Health in Voorhees, New Jersey. Learn more at http://www.thecnnh.org/.