In this blog, I wanted to address myths about autism because, generally speaking, when people do not have the knowledge or access to key information they often depend on the knowledge of family and friends that may not always be 100% accurate. Of course this can depend on educational level and socioeconomic status as well. People also make assumptions based on what they have seen or heard. The myths and FACTS are as follows:
Fact: Although, there is no cure for autism, intensive behavioral treatment helps children with autism develop communication and social skills they lack.
- Autism is caused by vaccinations
Fact: There is no evidence that autism is caused by vaccines. The study which correlated the two, published in 1998, was debunked.
- Autism is caused by "cold parents"
Fact: Autism is a neurodevelopmental disorder that is believed to be genetically and environmentally based. It does not have anything to do with parental treatment.
- Kids with autism lack cognitive deficits
Fact: Not all children with autism have cognitive impairments. Rather, some higher functioning children instead lack the language and social skills to interact with others.
- Most autistic people are non-verbal or close to non-verbal
Fact: Not all people with autism are non-verbal - this depends on the level of severity; they range from non-verbal to highly verbal.
- People with autism are intellectually disabled
Fact: Many people with autism have normal to high IQ's; some have exceptional abilities in math, music, art, etc.
- Everyone with autism behaves in the same manner
Fact: Like anyone else, people with autism have unique qualities and strengths weaknesses.
Fact: Autism is not rare; it affects 1 in 68 children (Falco)
It is best to seek out credible sources when learning about autism. This is especially important for those who are working with the population or have a family member with autism. It is highly recommended that you learn about their capacities and unique abilities so that you can help provide them with optimal communicative, social, and learning opportunities.
Falco, Miriam (2014). Autism Rates now 1 in 68 U.S. children. CNN Health. Retrieved from http://www.cnn.com/2014/03/27/health/cdc-autism/
Childmind Institute. Retrieved from http://www.childmind.org/en/myths-about-autism/
Autism Resource Foundation. Retrieved from http://www.autismresourcefoundation.org/info/info.misconceptions.html
Autism speaks. Retrieved from www.autismspeaks.org
Geneva Centre for Autism. Retrieved from https://www.autism.net/resources/about-autism/43-autism-spectrum-disorder-asd-myths-and-facts.html
In addition to social impairments, communication impairments and repetitive behaviors, children with autism demonstrate atypical attention, which impacts core areas of the diagnosis. Although this is a problem area, there is little research on how to treat "attention." Attention is broken down into three broad categories of orienting, sustaining, and shifting.
Orientation attention is defined as the initial physical adjustment toward a stimulus, or a gaze, shift, head turn. Impairments in orienting have been reported as early as 8-10 months in children that have later been diagnosed. According to Watson and Watson (2011) this may be one of the earliest observable symptoms of autism. The deficits in orientation can have implications for intervention because if the materials you bring into your session fail to draw the attention of the child with autism they will not have the "desired teaching impact."
Sustaining attention is defined as the ability to maintain attention, or ongoing regard of an object or event. Children with autism tend to become fixated on one aspect of the stimulus and ignore the others. For example, in a book with numbers and pictures of course, they might become fixated on the numbers and ignore the pictures.
Shifting attention is defined as the ability to disengage from one stimulus and then shift and reorient to another. For example, if a child is focused or engaged in attending to a particular toy, the child must first disengage their attention from that toy and then shift their attention to a new one.
Patten and Watson (2011) reviewed evidence-based intervention strategies for attention and what the outcomes were. Three approaches are described below:
The first approach is the "Natural Behavioral Interventions; Natural Milieu" in which the teaching takes place in the natural environment. Modeling and prompts are given as needed. The environment is arranged as needed to elicit specific behaviors. According to Patten and Watson (2011), as per reviewed literature, this approach increased for 4/5 participants. This was a single subject, multiple baselines across participants design. Treatment consisted of eight 20-minute sessions over a period of 10 weeks.
The second approach is similar to the first except it is parent/peer mediated. In early intervention with parent training this is really what therapy should look like once parents have been trained. "Peer/parent mediated within natural milieu natural behavioral interventions." In this approach, parents/peers are taught to initiate or direct specific types of behavior. Teaching also takes place in the natural environment, etc. According to Patten and Watson (2011) all three participants made gains in joint attention. This was a single subject design across multiple baselines including qualitative data. Treatment was carried out for 16-19 weeks, one hour per day.
The third approach is Applied Behavior Analysis (ABA). ABA stems from behavioral leaning theories in which closer and closer approximations of desired behaviors are rewarded. Undesired behaviors are not reinforced or have aversive consequences. Joint attention response improved in all three participants. This was a multiple baseline design. Treatment consisted of 25-42 10-20 minute sessions over a 3-week period.
In conclusion, abnormalities in the attention skills of young children with autism are widely prevalent and are often seen in therapy. However, there is only a small body of research that addresses attention as described by Patten and Watson (2011). This article concludes that despite the strategy used to target attention, children with autism benefit from intervention to improve attention whether therapists, peers or family carries it out. Attention should be a simultaneous target with language because in order to learn language the child must attend. Attention is an underpinning for the learning of many skills.
Reference: Patten, E; Watson, L.R (February 2011). "Interventions Targettinf Young Children with Autism". American Journal of Speech Language Pathology. Vol. 20 (Pages 60-69). Retrieved from ajslp.pubs.asha.org.
Many families think about the future care of their child when they are diagnosed with autism, or any other disorder for that matter. A family once asked me if their child would be self-sufficient one day or if they would require life long parental support. This was a question that I did not anticipate and found extremely difficult to answer. The Autism Society suggests consideration of the following for future planning of a child with autism or any other type of special need:
- Guardianship - At three points in your child's life guardianship is crucial: during childhood, upon reaching the age of 18, and during adulthood. The Autism Society says that if you assume responsibility for your adult child, you must name a legal guardian upon your passing.
- Benefits Assessment - An attorney specialized in children with special needs can determine what benefits the child may be eligible for as far as government assistance is concerned. A financial advisor can also help devise a savings plan.
- A Special Needs Trust (SNT) - An SNT can help supplement any government support or assistance received. There are several types of SNTs. An SNT allows the family to leave money for the care of their loved one. This does not reportedly affect any monies received through government aid (e.g. Supplemental Security Income (SSI) and Medicaid benefits). The SNT also ensures that assets are managed responsibly.
- Letter of Intent (LOI) - The letter of intent is like a roadmap that helps guide guardians, trustees and others on how to care for your child with autism when you are no longer able to. Medical, financial, legal and personal details are discussed in this letter.
- Powers of Attorney - If guardianship is not completely necessary for the adult with autism, other alternatives are available that name agents responsible for specific types of decision-making.
- Will - A will details the disposition of your property upon passing. It establishes the portion of your estate that you like to allocate to your child with disabilities as well as other heirs and whether or not certain funds should be held by an SNT.
Reference: Autism Society. Future Planning. Retrieved from www.autism-society.org
Most families that have a child with special needs often go through a grieving process. As clinicians going into the home, it is important that we understand this grieving process so that we can better understand the family we are working with. Often, as clinicians we may experience transference from the family, or the family's redirected feelings towards the therapist.
As you may be aware, the grieving process including the following: shock, sadness, anger, denial, loneliness and acceptance. Remember, prior to a diagnosis of ASD families have so many expectations for their child and the diagnosis changes their lives completely. Occasionally, I have experienced the family's stress in session, including difficulty accepting the diagnosis, which may manifest itself through defensiveness to suggestions or responses they sought information for. Also, parents may question you about their child's behavior that may be directly related to ASD, and then try to justify it as something unrelated to ASD. They may also elevate how much language the child is using, which has not been observed in your sessions.
Reportedly, mothers experience more stress since they are the primary caregivers in most cases. According to research, several reasons for stress include:
- Accepting the diagnosis
- Feeling overwhelmed by the lack of understanding about ASD and what it means for their child
- Feeling uncertainty or little control about the future of their child with ASD
- Difficulty handling the child's challenging behavior, including how the child interacts with others
- Difficulty navigating the ASD service system
- Managing daily life with a child with ASD
According to parents with children that have a child with ASD the following has been helpful for managing their stress:
- Prepare yourself for situations that cause potential stress. Practice healthy coping responses to those stressful situations.
- The more you know about how your child's ASD characteristics affect their learning and development, the better equipped you'll be to minimize and avoid stress.
- Be aware that family members will respond differently to your child with ASD. Their experiences of stress will also be different.
- Connect with service providers and other parents in similar situations so your family is supported
Remember, when you work in EI especially and you agree to work with a child that has ASD you are not only working with that child, you are also working with the family. It is important to understand what the family is going through so that you can determine how to help them. Also, don't take their defensiveness personal as they are undergoing huge life changes. You want to be part of a positive therapeutic experience especially in those early years that can set their tone on therapy for years to come. Also, we make an important mark in their lives since we are often the first providers they work with. As a clinician, I want my families to look back and remember how dedicated and understanding I was while working with them and their child.
Reference: Raising Children Network (2013). Autism Spectrum Disorder and Family Stress. www.raisingchildren.net.au
Attention deficit hyperactivity disorder (ADHD), anxiety disorders such as specific phobias, obsessive compulsive disorder (OCD), social anxiety and mood disorders including bipolar disorder, depression, and oppositional defiant disorders can co-occur with ASD. For treatment purposes, it is important to understand how these comorbid conditions can impact therapy. Also, as clinicians we must have realistic expectations of the child with ASD that we are treating because the comorbid conditions can limit the child's therapeutic progress significantly. Another factor to consider is that children with ASD may be mistakenly diagnosed with one of the above-mentioned disorders.
According to Harrison (2013), one third of children with ASD meet the diagnostic criteria for ADHD. ADHD is one of the most common childhood disorders and can continue through adolescence and adulthood. Symptoms include the following: difficulty staying focused and paying attention, difficulty controlling behavior and hyperactivity (over-activity). According to Kennedy Krieger Institute, as published in Autism: The International Journal and Practice, findings revealed that children with both ASD and ADHD have significantly more cognitive, social and adaptive functioning impairments in comparison to children with ASD only. The DSM IV prohibited a comorbid diagnosis of ASD and ADHD. However, with the new DSM V, this is no longer the case. Currently, this is a topic that is often debated by researchers due to differing opinions and/or research findings.
According to Van Steensel, Bogels & Perrin (2011), 39.6% of "young people" with ASD have anxiety disorders. The most frequent anxiety disorder is specific phobia with 29.8%. OCD was followed with 17.4% and 16.6% with social anxiety. Furthermore, Van Steensel et al. reported that the rates of anxiety disorders observed in children with ASD are more than two times higher when compared to typically developing children (as cited in Costello et al. 2005). According to Russels, Cols, Anson & Murphy (2005) in a comparative study of individuals with comorbid disorders of ASD/ OCD and subjects with OCD only, the ASD/OCD group reported obsessional thoughts of cleaning, checking and counting symptoms. However, they were more likely to report repeating, hoarding, touching, tapping and self-damaging behaviors than the participants with OCD. OCD is also reportedly more prevalent in higher functioning children with ASD.
According to Autism Speaks, studies suggest that bipolar disorder may be common among children and adults with autism with as many as 27%. Although, it is reported that bipolar disorder is mistakenly over-diagnosed in those with autism consequent to overlapping symptoms and strong similarities. In a study including teens with autism, researchers found that nearly a third had frequent episodes of "elevated mood" described as irritability, "excessive talking," engaging in "excessive activity" and with a tendency to get into trouble. These behaviors could be considered symptoms of bipolar disorder, they stated. However, the majority of these children did not reportedly have bipolar disorder. In most cases, these symptoms were mere aspects of their autism and not bipolar disorder. Regarding differential diagnosis, the researchers found that they could tease the symptoms apart by analyzing when the symptoms appeared and their longevity.
When you are assigned a child with ASD as part of your caseload, it is important to consider comorbid diagnoses or potential undiagnosed comorbid disorders. Make observations, interview the families and consult other providers working with the child in order to learn more about the child's behaviors. Also, remember that there is a fine line between ASD and some of the above-mentioned disorders. According to Ovsanna et al. (2006), it can be challenging to determine if the difficulties a child with ASD experience are due to the core features of ASD or to a comorbid disorder. Unfortunately, some children are misdiagnosed but all we can do is make our own judgments based on direct observations, family interviews and consultations with other rendering providers. Finally, as informed clinicians it is also of clinical significance that we stay abreast of current research which can impact our views and how we carry out therapy.
Harrison, P (2013). Medscape. High Proportion of Children with Autism Also Have ADHD. Retrieved from www.Medscape.com
Ovsanna, T.F; Folstein, S.E; Bacalman, S; Davis, N.O; Dinh, E; Morgan, J; Tager, H.F; LeinHart, J (2006). Comorbid psychiatric disorders in children with Autism: Interview development and rates of disorders. Journal of Autism Developmental Disorders. (36) 849-864.
Van Steensel, F.J; Bogels, S.M; Perrin, S. Anxiety Disorders in Children and Adolescents with Autistic Spectrum Disorders: A Meta-Analysis. Clinical Child Family Psychology Review. Sep 2011; 14(3): 302-317. Retrieved from www.NCBI.nim.nih.gov
Autism Speaks. Treatment for Associated Psychiatric Conditions. Retrieved from www.AutismSpeaks.org.
During speech and language evaluations it is important to involve the parents and take reports about their child into account. As an evaluator, you are in the home for such a short period of time and do not get a complete picture of the child's true capabilities. In using the Rossetti for children from birth-three years of age, behaviors can be directly elicited from the child, directly observed, or reported by a parent or caregiver to give the child credit. Whether observed, elicited or reported, all forms carry equal weight for the purpose of scoring in which you determine age equivalent ranges. Parents can also carry an enormous amount of stress especially when they feel their child is not performing or behaving as they typically would. The family is probably already coping with the fact that their child has a delay and is so overwhelmed by the time you evaluate their child.
I always explain to the families that I will need their feedback, as it is very valuable. As mentioned above, I tell them that I need their feedback regarding behaviors because I will not get a full picture of the child in the period of time that I am there. I also encourage the parents to participate and often prompt them throughout the evaluation to elicit certain behaviors if not observed. I also explain that I like to observe what their child can do without directives or cues so they are not caught off guard during the evaluation when I ask them not to direct the child. This is hard for parents even when you ask them not to do it because they are so use to helping their child with directives. Then, I tell them that if their child is unable to complete a particular task that we can direct them. Remember children are always more comfortable with their parents especially when a "stranger" comes into the home and tries to interact with them. Therefore, they might be more willing to complete a task when asked by their parents.
Another factor to consider is when multiple evaluators have gone into the home. Every evaluator (domain specific) has their own way of conducting an evaluation. I think that when you are the last evaluator to go into the home, families have certain expectations. Their expectations come from specific experiences with the prior evaluators. For example, if the prior evaluators did not include parents while eliciting target behaviors they may expect you to do the same. So they may be surprised when you ask them to participate. I am not sure how much parent involvement is required for other domain specific evaluations (other than for interviews) but for speech and language it is pertinent.
There are clinical implications for children with a suspected autism spectrum disorder during an evaluation. Since children with autism have difficulty interacting with others it may be difficult to engage them without assistance from the family. My message in this blog is to make families feel as comfortable as possible during an evaluation and reassure them that their feedback is valuable, as they know their child best. The families have a long road ahead of them especially when their child has a suspected ASD. Often families' early experiences with Early Intervention start with the evaluations. I like to make a positive mark in the lives of the families and children that I work with. I really think these early positive experiences can help foster a sense of teamwork, which will be necessary throughout the treatment process.
In an article by Plum and Weatherby (2013) they compared the vocalizations of three different groups, described as the "typically developing" (TD), "developmentally delayed" (DD) and "autistic spectrum disorder" (ASD) group. This study had three objectives, however, I focused on the following objective: Compare communicative and non-communicative vocalizations displayed between children 18 and 24 months of age. They define vocalizations as phonetic complexity and syllable structure.
Findings revealed that when children with autism vocalized it was with less communicative intent. Furthermore, when vocalizing communicatively, they were less likely to do so for joint attention when compared to the DD and TD groups. According to Plum & Weatherby this is consistent with the fact that children with ASD have difficulty communicating for joint attention. All three groups also used non-transcribable vocalizations, which were defined as a non-syllabic vocalization with a vowel and atypical phonation. However, when compared to the DD group, the ASD group used it more during acts of behavior regulation. Overall, the ASD group produced more vocalizations for acts in behavior regulation than for acts in joint attention. Plum & Weatherby also found one vocalization that set the ASD group apart from the rest. The ASD group produced more "distress" vocalizations (e.g. cries, whines, screams) and this is consistent with the difficulties in regulating emotions that most children ASD experience.
Based on their findings, there are implications for early identification and early intervention services between the ages of 18 and 24 months. Plum & Weatherby suggest keeping a close eye on distress vocalizations during screenings and evaluations. They state that increased frequency of distress vocalizations can be a severe red flag of autism. Also, according to Plum & Weatherby, emotional dysregulation should be a session target because it decreases optimal arousal levels which are necessary for learning and development. They encourage SLPs to target communication to express the functions of behavior regulation, joint attention, and social interaction. Plum & Weatherby indicate this may decrease distress vocalizations associated with communicating basic need and wants and simultaneously increase reciprocal social interactions.
Reference: Plum AM and Weatherby AM. "Vocalizations in toddlers with autism spectrum disorder." Language, Speech, and Hearing Research. 56(2013): 721-734. Retrieved from jlshr.pubs.asha.org
In reading the article, "Interdisciplinary Assessment of Young Children with Autism Spectrum Disorder," the section on cultural competence drew my attention. Prelon, Beatson, Bitner, Broder & Ducker (2003) describe cultural competence as a continuum.
Prelong et al. describe the bottom of the continuum as destructiveness. In this phase, the SLP views the family's culture as a "pathology" in which access to appropriate services is potentially blocked. Next on the continuum is described as cultural incapacity. This is described as the phase in which the SLP demonstrates low expectations for the language minority child. In addition, the SLP displays few cross-cultural skills. Cultural blindness is when SLP's do not think about cultural differences or see them as stereotypical. Furthermore, as part of pre-competence the SLP begins to recognize their own cultural beliefs and biases. The SLP reaches cultural competence when they are able to acknowledge and accept the cultural differences. The final step of the continuum is cultural proficiency, which the SLP has reached once they begin to serve as mentors, teachers and collaborate or contribute to the field.
In our field, it is important to consider cultural factors because overall communication, including social norms, can vary significantly from one culture to another. As clinicians we should be metacognitive about our own cultural bias so that we can provide culturally appropriate services or at least get on the right path.
The following is recommended for a strong bilingual EI program:
- Demonstrate a positive attitude towards the native language and create a sense of collaboration with English to support bilingual language development.
- Teach language concepts (e.g., naming, requesting, commenting) instead of teaching English (or home language) vocabulary skills only.
- Use culturally appropriate materials and incorporate the native language and cultural rituals into the therapeutic activities (e.g., songs, books, facilitated play activities, etc.).
- Present written material in both languages to ensure greatest understanding.
- Investigate and share information on the development of the native language and
- bilingualism overall, instead of translating information regarding English language development.
CSHA Diversity Committee 2003-2004. Early Intervention For Culturally and Linguistically Diverse (CLD) Populations. http://old.csha.org/documents/diversity/EARLYINTERVENTION.pdf
Prelock AP et al. "Interdisciplinary Assessment of Young Children with Autism Spectrum Disorder". Language, Speech, and Hearing Services in Schools. 34(2003):194-202. LHSS.pubs.asha.org
In the article, Issues in Bilingualism and Heritage Language Maintenance: Perspectives of Minority-Language Mothers of Children With Autism Spectrum Disorders, Betty Yu discusses bilingualism in children with autism. She indicates that families of children with ASD are often reluctant to speak to their children in their native language for fear of confusing the child or "exacerbating" the impairment. As SLPs in a culturally and linguistically diverse country, we are key to helping families understand the role of their native language in the child's impaired language development. Yu emphasizes the message often given to families by professionals in the field that they should speak English only.
Yu states that encouraging parents to speak English only contradicts ASHA's position statement (2004, 2005, 2011), which urges practitioners to regard the families' cultural and linguistic preferences. Yu indicates that native languages are key to the following:
- facilitation of cultural identification
- transmitting family values
- fostering intimacy
- promoting attachment
She moves on to say that asking parents to speak English only is unsupported by research. Yu cites Genesee, Paradis, and Crago (2004), who argue the inappropriateness of advising that children with language impairment should learn only one language. She continues to cite Paradis and Crago, indicating that the circumstances of each child should be individually assessed to determine whether dual language use is suitable.
Yu indicates that only a few studies to date have been conducted with children that have autism as far as bilingualism is concerned. One study Yu cites was conducted by Hambly and Fombone (2012) which compared three groups of children. One was a monolingual group, the next was bilingually exposed for 12 months prior to the study, and the last was bilingually exposed 12 months after the study. Hambly and Fombone assessed the following: social responsiveness, initiating of pointing, response to pointing, attention to voice, total conceptual vocabulary, words in dominant and second languages, age of first words, and age of first phrases. Their study concluded that children with ASD that were bilingually exposed did not demonstrate additional delays compared to their monolingual counterparts. No significant difference was found in those particular skills between bilingual children that were raised bilingually vs. sequential bilingual environments. Hambly and Fombone (2002) reported that 60% of the bilingually exposed children were observed to be acquiring vocabulary in two languages. Yu cites other studies as well in this article.
As Paradis and Crago stated, the circumstances for each individual child should be assessed. Some questions or factors to consider might be the following:
- Are the parents fluent English speakers, bilingual as well? - If the parents are fluent in English they may choose this language over the native one until the child demonstrates the ability to communicate proficiently in English.
- Is English language proficiency limited? - If English proficiency is limited in the family then this may limit language rich vocabulary.
- Is the family more "Americanized" or acculturated? If so, to what extent? - Some families might highly value American culture and want their child to speak English first.
- Does the child attend preschool? - Some parents might fear that if they speak their native language their child might have a hard time communicating in English with other children in the community or a school setting.
I would never ask a family to speak English only if their English language proficiency was very poor because this compromises their ability to give their child a rich vocabulary. I always advise parents to speak to their children in their language rich vocabulary and I explain why, whether they have ASD or not. Often, parents of bilingual children fear that two languages might confuse their child or worsen the delay. However, this is not the case. Although, if you are working with a bilingual family that is also English proficient, you can explain the benefits of bilingualism but they ultimately decide which language they feel is best for their child. It is important to explain the benefits of bilingualism and be able to answer or clear up any doubt the family might have to help them make an informed decision regarding language use.
Yu B. "Issues in bilingualism and heritage language maintenance: perspectives of minority-language mothers of children with autism spectrum disorders." American Journal of Speech Language Pathology. 22.10-24(2013). ajslp.pubs.asha.org.
Sensory Processing Disorders (SPD) and autism (ASD) are two conditions that can exist one without the other or they can be comorbid. Making a clear distinction between the two is important especially since SPD can look like autism. SPD is diagnosed by an occupational therapist that is trained in sensory integration. A child with SPD can easily be misdiagnosed for a child with ASD due to sensory processing problems/symptoms children with autism experience. As I have defined in previous blogs, ASD is a neurological disorder that affects normal brain function and significantly impacts development of the person's communication and social interaction skills. SPD was formerly known as "sensory integration dysfunction." Our neurological system helps process signals received from our senses by turning them into appropriate motor and behavioral responses. Therefore, SPD affects how a person receives, integrates and makes sense of sensory information.
According to the Sensory Processing Disorders Organization, 1 in 20 children suffer from SPD. In addition, high rates of SPD are often found in children with autism. However, according to the SPD Foundation most children with SPD do not have autism. They are described as two separate conditions. Consequent to similarities, children with SPD run the risk of misdiagnosis.
The following are signs of SPD in infants:
- Problems eating
- Trouble falling asleep or staying asleep
- Extremely irritable when I dress him/her; seems to be uncomfortable in clothes.
- Rarely plays with toys, especially those requiring dexterity
- Difficulty shifting focus from one object/activity to another
- Does not notice pain or is slow to respond when hurt
- Resists cuddling, arches back away from the person holding him
- Cannot calm self by sucking on a pacifier, looking at toys, or listening to my voice
- Has a "floppy" body, bumps into things and has poor balance
- Does little or no babbling, vocalizing
- Is easily startled
- Extremely active and is constantly moving body/limbs or runs endlessly
- Seems to be delayed in crawling, standing, walking or running
The symptoms will vary depending on the age group. The above-mentioned symptoms are distinct to SPD, not autism. However, these two conditions do coexist. So if you come across a child on your caseload with sensory processing difficulties, before you think autism consider the child’s social and communication skills. In addition, consider if the child exhibits any repetitive behaviors. The child may very well have SPD and not a suspected autism.
Reference: Sensory Processing Foundation. Retrieved from www.spdfoundation.net.
I recently came across an article by researchers, Dr. Jones and Dr. Klin from Autism Speaks Baby Siblings Research Consortium (BSRC). They studied a total of 110 infants, 59 of which were considered "high risk" consequent to having a sibling on the spectrum. The remaining subjects did not have a family history of ASD. Eye tracking technology was utilized to measure social cue responses as presented through a video of a "friendly caregiver."
Each infant was tested a total of 10 times between the ages of 2 and 24 months. According to the researchers, baseline levels demonstrated similarities in eye contact between the two groups of infants. They found that infants who did not develop autism increased eye contact over time, as expected in development. On the other hand, eye contact declined for the 13 infants that were later diagnosed with autism. Twelve out of the thirteen later diagnosed were from the "high risk" group. Furthermore, they reported eye contact rapidly declined by age 3.
The decline in eye contact was detectable through eye tracking technology only and not the naked eye. According to Dr. Wang, Autism Speaks vice president for Medical Research, "The new eye-gaze findings suggest that subtle symptoms can be present at a very young age and that these very early symptoms may continue to worsen over time." However, he adds that the study was too small to conclude if this technology would be used in the future to diagnose autism.
I thought the findings were very informative but was disappointed to learn that the decline in eye contact was not visible to the naked eye. Visible declines in eye contact can be an important indicator, if noticed. Even though the declines are not reportedly visible to the naked eye it is important that caregivers be alert for potential noticeable declines. A child with a potential risk for a diagnosis of ASD will eventually reach a point in which eye contact will noticeably diminish. In addition to declines in eye contact, other red flags should be considered in conjunction.
With the increasing rates of autism in the United States, families should educate themselves on early warning signs especially when there is a family history or if the child is not reaching expected milestones. Pediatricians also play an important role as they track child development through well-child care visits. However, parents know their children best and with the right information can help detect a problem early on which can potentially lead to a more desirable outcome later.
Reference: Study: Eye Contact Declines Early in Babies Who Later Develop Autism. (November 2013). Science News. Retrieved from www.AutismSpeaks.org.
In one of my initial blogs, I discussed how it is not within the scope of the speech pathologist to diagnose autism. However, I would like to emphasize that this is not the case when working as part of a diagnostic team. According to ASHA's position statement (2006), under diagnosis:
"Speech-language pathologists who acquire and maintain the necessary knowledge and skills can diagnose ASD, typically as part of a diagnostic team or in other multidisciplinary collaborations, and the process of diagnosis should include appropriate referrals to rule out other conditions and facilitate access to comprehensive services." (www.asha.org)
I would also like to clarify that if you are a therapist rendering services and suspect autism consequent to the symptoms as defined by the new diagnostic criteria in the DSM V, you cannot diagnose the child. It must be done as part of a diagnostic team. By the time the SLP begins providing services in the home, the child has already been evaluated. However, at that point you can make a referral for a psychological evaluation but not diagnose.
According to ASHA, SLP's are often the first to notice communication deficits and social limitations. This is true because during the evaluation process we are often one of the first providers to enter the home. Therefore, it is urgent to communicate your findings with other professionals that evaluate the child regarding any potential red flags. Appropriate referrals and diagnoses can be made even before initiation of services if the red flags are detected and communicated. Early intervention services are always beneficial especially for a child with a potential diagnosis of ASD.
I would also like to add that Autism Speaks has a video glossary in which both parents and professionals can learn about the early symptoms of ASD. There are over 100 video clips available for your viewing. It is free of charge and viewers must register to access. This glossary could be helpful for professionals across domains. Furthermore, the videos can help confirm if observed behaviors are in fact red flags.
Please feel free to share your experiences as they relate to this topic. I would love to hear about them!
Autism Speaks offers a manual for families of children that have been diagnosed with autism which is described, as "critical information families need the first 100 days after an autism diagnosis." The manual is 66 pages and is available in Spanish as well. The Spanish version is a bit lengthier at 84 pages. "The 100 Day Kit" is divided into the following five sections: About Autism; You, Your Family & Autism; Getting Your Child Services; Treating Autism; and Making It Happen. In addition, the manual contains useful forms, a glossary and information on local resources.
The "All About Autism" chapter defines autism and discusses how it is diagnosed. In addition, it provides statistical information and medical issues that may coincide with the diagnosis, etc. "The You, Your Family & Autism" chapter discusses the impact on the family and provides readers with useful tips. "Getting Your Child Services" helps guide families with accessing services and discusses special education and the child's rights. The last chapter, "Treating Autism" describes a variety of interventions.
The manual can be accessed through the Autism Speaks website under the "Family Services" tab under "Tool Kit." There is a short request form to complete. The manual is free for families that have a child that has been diagnosed within six months of the date the manual is requested. Otherwise, it can be purchased. It is also free for professionals that work with the population. It is a great resource for anyone working in the field especially if you are a new provider that would like to help guide your families. You can also refer your families to the comprehensive manual. If the family does not have access to a computer, perhaps you can print out some of the most important pages and share it with them.
In my opinion, this is a great way to empower your families, especially those with limited access to information. It provides them with key information and can serve as a guide. Furthermore, it can help minimize some of the anxiety and stress that can accompany a new diagnosis. Check out the manual and feel free to share your opinions!!
Targeting pragmatic goals can be a challenge within the context of the Early Intervention setting. There are a few challenges that can arise when trying to target these goals. Consider the following, as you may find some of these in common as well: scheduling conflicts, limited opportunities for contact with other children during community outings, and parent reluctance to go into the community.
Scheduling conflicts due to child or clinician availability can make it difficult to schedule a session in the community. If your session is scheduled for an evening time families may be more reluctant to go into the community, especially after they come home from work. If this is a factor then perhaps you can ask the family how they would feel about a play date with one of the child's little friends. A play date in the family home can be a great idea because you can structure the session and control the environment to a certain extent. This is probably one of the best ways to create social opportunities for that child and most optimal to train the parents during your EI sessions.
Even if you are able to go into the community it may be difficult to structure your session with other children for a number of reasons. Controlling the environment outside of the home is difficult because of the unpredictability. However, some places that might work for your session are a park or library. If you have your session in a park you want to ensure you are there during a time of the day in which you will find age matched peers in order to promote social communication and create social opportunities for that child. Most libraries have reading/literacy groups for children of different ages in which you can also create social opportunities. Taking community outings to stores (supermarket, local drugstore, local grocery store, etc.) and having the child pay in order to use social greetings could be a way of targeting some pragmatic goals. Community outings are also a great way of modeling social language for the child.
Parent reluctance can probably pose the greatest challenge. If the family is unwilling to go into the community then it is out of your control. I would not press the family to do something they are not comfortable with. The family may even have reasons they may be unwilling to share. However, if you have established good rapport with the family then they may be willing to share it with you. If you sense reluctance then you can gradually present the idea and feel them out. Perhaps you can start with a play date and if that is successful they may change their minds about going into the community.
How have you approached the topic of community outings with your families?
Transference and countertransference are naturally occurring phenomena in relationships. Under a therapeutic lens, transference has to do with specific feelings a client can have towards a therapist, countertransference has to do with feelings a therapist can have towards a client. These may occur without our own awareness, and can in fact impact your actions and responses towards your client in therapy. This phenomenon can affect how you feel towards a client and vice versa.
Transference and countertransference can work for or against you in therapy.
Consider the following example of transference: You remind your client of someone in their family. If they dislike this person, it may have a negative impact on your relationship and reflect in your therapy. However, if the child's feelings towards that person are positive, that may help nurture a good relationship between you and your little client.
Considering countertransference, if a client or even their family reminds you of someone, your treatment towards the current client/family may be affected by your past feelings or relationship. For example, you may treat some families preferentially without realizing it, if the similar past client/family relationship or feelings were positive.
It is important to understand and have a certain level of metacognition with both transference and countertransference as they can impact therapy. If not identified and managed accordingly, the therapeutic relationship can flourish or become stagnant early on. However, no matter the feelings, maintaining a certain level professionalism is important. Understanding how to manage those feelings should be considered in order to create a positive therapeutic environment. Children can easily pick up on the feelings of those around them (e.g. anxiety, contentment, anger, etc.). Your little clients deserve the best of you and a good place to start is by opening your mind to how your behaviors and feelings impact your clients in therapy.
Have you have experienced transference and/or countertransference? How did you manage it? I would love to hear from you!