Abstract
Autism Spectrum Disorder (ASD) is considered to be an umbrella term for neurodevelopmental disorders such as autism, Asperger syndrome and pervasive developmental disorder (PDD). Argued to be found in 1 in 100 individuals, ASD has been gaining considerable interest both in the general public and by medical, educational, and psychological professionals. This increase in interest has meant a widening in our understanding of the causes and characteristics of ASD in both children and adults. The proceeding sections will describe and summarise the vast amount of literature that is currently available about ASD, and end with educational consideration which have emerged as a result of our increased understanding.
1. Definition and Description of ASD
1.1 Definition
The first systematic descriptions of autism emerged in the 1940s by Leo Kanner (1943) and Hans Asperger (1944). The works of these researchers were done independently, however both Kanner and Asperger used the term ‘autistic’ when referring to the children they were observing (Hallahan, Kauffman, & Pullen, 2014). Kanner made important distinctions between children with autism and children with schizophrenia, such that 1) children with schizophrenia tended to withdraw from the environment, children with autism tended not to have made initial social connections; 2) children with autism exhibited unusual language patterns (e.g. echolalia); and 3) functioning of children with autism did not deteriorate over time like some of the children with schizophrenia (Hallahan, Kauffman, & Pullen, 2014). Asperger’s added to Kanner’s work by finding two significant exceptions. The children observed were of average intelligence, and it appeared that their language was ‘normal’ (Hallahan, Kauffman, & Pullen, 2014).
Under the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013), ASD encompasses a large spectrum of disorders including Asperger syndrome, autism and pervasive developmental disorder (PDD) (Gotham, Bishop, and Lord, 2011; Hallahan, Kauffman, and Pullen, 2014). Autism is a neurodevelopmental disorder with onset in infancy or early childhood, and comprises of both delays and deviance in mutual social interaction, communication, and constrained and repetitive behaviours and interests (Gotham, Bishop & Lord, 2011). Asperger syndrome is another common diagnostic classification under ASD, and is often defined by the same triad of behavioural domains attached to the definition of autism (Molloy & Vasil, 2004).
1.2 Diagnostic Criteria
The APA recommends under the DSM-5 (2013) that for a diagnosis of ASD to be delivered, the individual must meet the proceeding criteria:
A. Persistent insufficiencies in social communication and interaction across several environments, as displayed by all of the following:
1. Deficits in social-emotional reciprocity (e.g. inability to apply typical back-and-forth dialogue).
2. Shortages in nonverbal communicative behaviours used for social interaction (e.g. absence of facial expressions and nonverbal interaction).
3. Deficits in developing, upholding, and comprehending relationships (e.g. difficulties altering behaviour to suit numerous social settings).
B. Constrained, repetitive patterns of behaviour, interests, or activities, as displayed by at least two of the following:
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g. lining up toys).
2. Insistence on uniformity, uncompromising obedience to routines, or ritualised patterns of verbal or nonverbal behaviour (e.g. severe distress at minor changes).
3. Greatly constrained, fixated interests which are irregular in strength and/or focus (e.g. strong attachment with unusual objects).
4. Hyper- or hyporeactivity to sensory effort or abnormal interest in sensory parts of one’s surroundings (e.g. extreme smelling or touching of objects).
C. Symptoms are required to occur during the early developmental stages (but may not become fully apparent until social stresses surpass limited capabilities, or may be concealed by learned strategies in later life).
D. Symptoms must cause clinically significant impairment in occupational, social or other significant areas of present functioning.
E. These disruptions are not better explained by intellectual disability of global developmental delay (APA, 2013).
The proceeding sections will pay particular attention to autism and Asperger’s syndrome, as these are among the most common disorders along the spectrum classified by the current DSM (DSM-5).
2. Prevalence and Aetiology
2.1 Prevalence
The prevalence rates for ASD are continuously changing, with estimates argued to be increasing dramatically (Hallahan, Kauffman, & Pullen, 2014). The first widespread epidemiological investigation of autism conducted by Lotter in 1966 found a prevalence rate of around 0.04% (1 out of 2500) (Lotter, 1966 as cited in Hallahan, Kauffman, & Pullen, 2014). Whilst further surveys in the 1970s and 1980s found comparable rates, surveys conducted since 2000 have found noticeably higher rates for ASD (Hallahan, Kauffman, & Pullen, 2014). For example, the U.S. Centers for Disease Control and Prevention (CDC) provided an ‘official’ prevalence rate of 1 in 59 children in 2014 (CDC, 2018). And to put this into the New Zealand context, the Ministry of Health has published an estimated rate of 1 in 100 New Zealanders, and 1 in 45 children, being affected by ASD (Ministry of Health, 2017).
Arguments as to the reason behind such increases in rates of ASD can be divided into two scientifically justifiable ‘camps’ (Hallahan, Kauffman, & Pullen, 2014). The first position argues that the increase can be explained by three factors – 1) the widening of the diagnostic criteria for autism, including the increased recognition of milder forms such as Asperger syndrome; 2) a wider awareness of autism in the general population as well as within professions such as medicine, education and psychology; and 3) the phenomenon of ‘diagnostic substitution’, such that individuals who would have been diagnosed as intellectually disabled or having developmental language disorder are now being diagnosed with an ASD (Bishop, Whitehouse, Watt, & Line, 2009; Coo et al., 2008 as cited in Hallahan, Kauffman, & Pullen, 2014). The second position argues that even though the former may account for some of the increase, these may not account for the total increase and therefore, one cannot rule out the possibility of other unknown factors causing a rise in the number of cases (Hertz-Picciotto & Delwiche, 2009 as cited in Hallahan, Kauffman, & Pullen, 2014).
2.2 Aetiology
2.2.1 Early Causal Theories
Deemed as the ‘Biology vs. Refrigerator Parents’ era, the twentieth century saw the dominance of the Freudian hypothesis (Rapin, 2011). Whilst Hans Asperger speculated that there was a biological and innate basis for autism, Kanner further emphasised that parents of autistic children lacked warmth (Rapin, 2011; Hallahan, Kauffman, & Pullen, 2014). Such speculation – that autism resulted from cold and unloving parents – wrongly became the dominant belief prior to the 1970s (Redshaw & Smith, 2013).
2.2.2 Present Causal Theories
We are yet to know specifically what is not right in the brain of those with ASD, however scientists have recognised indisputably that the cause is neurological (Muller, 2007). The neurological basis of ASD is proposed due to the fact that individuals with autism have a high-occurrence of brain seizures and cognitive deficits (Volkmar & Pauls, 2003, as cited in Hallahan, Kauffman, & Pullen, 2014). Moreover, post-mortem and neurological imaging studies have associated ASD with a number of areas of the brain, leading researchers to suggest that autism may better be regarded as a disorder of neural networks, not as being due to an irregularity in one particular area of the brain (Hallahan, Kauffman, & Pullen, 2014). There has also been speculation regarding the brain, hormones, and head size of individuals with ASD, such that the heads of children with ASD appear to grow suddenly and markedly, followed by deceleration towards adolescence (Hallahan, Kauffman, & Pullen, 2014).
There is also strong evidence suggesting that genetics plays a role in numerous cases (Hallahan, Kauffman, & Pullen, 2014). Studies have found evidence of a hereditary component of autism, such that when a monozygotic twin has autism, the likelihood is much greater that the other twin will also have autism in comparison to dizygotic twins (Hallahan, Kauffman, & Pullen, 2014). Additionally, evidence now suggests that irregular genetic mutations are involved in some cases of ASD (Hallahan, Kauffman, & Pullen, 2014). It is argued that these mutations can result in ‘autism’, and can be handed down to children from one or both parents (Hallahan, Kauffman, & Pullen, 2014). Whilst the exact genes involved are yet to be identified, there is strong consensus among researchers that multiple genes are involved (Hallahan, Kauffman, & Pullen, 2014).
3. Behavioural and Learning Characteristics
3.1 Repetitive and stereotyped patterns of behaviour
It is argued that a number of individuals with autism displayed fixed motor or verbal behaviours (Hallahan, Kauffman, & Pullen, 2014). Such repetitive and ritualistic actions include, but are not limited to: flapping of the hands, spinning objects, rocking, and twirling (Hallahan, Kauffman, & Pullen, 2014). It is also common for individuals with autism to have limited interest, but excessively fixate on the small range of objects that are of interest – i.e. some children with autism play repetitively with an object for hours on end (Hallahan, Kauffman, & Pullen, 2014). Due to the nature of their actions and interests, individuals with autism can be easily upset by changes in the environment (e.g. a new addition to the home) or any changes in their usual routine (Hallahan, Kauffman, & Pullen, 2014). Some individuals with autism are adamant with maintaining sameness in their everyday life and routine, and therefore have great difficulty with change (Hallahan, Kauffman, & Pullen, 2014).
3.2 Impaired social interaction
Social reaction deficits are one form of social interaction issues that are often exhibited by individuals with autism (Hallahan, Kauffman, & Pullen, 2014). For example, a younger child with autism may not show any differences in their reaction to parents or siblings compared to strangers, or may show little interest in other people at all, but be rather fixated with objects (Hallahan, Kauffman, & Pullen, 2014). Such characteristics persevere and are likely to inhibit the child from developing ‘normal’ attachments to their parents or friendships (Hallahan, Kauffman, & Pullen, 2014).
For individuals with Asperger syndrome, impairment in social interactions are similar, but it is also argued that one of the main reasons for this impairment in individuals with Asperger syndrome is that they are not equipped to read social prompts (Hallahan, Kauffman, & Pullen, 2014). Furthermore, individuals with Asperger syndrome may struggle in their social interactions due to their tendency to be overly literal in how they read actions and languages of other people: such individuals often interpret situations using logic, and dismiss potential emotional aspects (Hallahan, Kauffman, & Pullen, 2014).
3.3 Impaired communication skills
Communicative intent, or the intent to communicate socially, is another factor which individuals with autism apparently lack. Scheuermann and Webber (2002) argue that as many as 50% of individuals with autism are understood to be mute, such that they appear to use no, or virtually no, language. The development of speech for some is accompanied with irregularities in rate, volume, pitch and content of their verbal language (Hallahan, Kauffman, & Pullen, 2014). Communication can sound mechanical, and some individuals with autism display echolalia, the repetition of another person’s oral speech (Hallahan, Kauffman, & Pullen, 2014). Those who develop language can use this as a tool for social interaction can be especially challenging, often due to their unawareness of their listeners’ responses (Hallahan, Kauffman, & Pullen, 2014). Furthermore, Adamson and colleagues (2009) argue that impairment in communication along with lack of social skills in children with autism are linked to deficits in their capabilities to engage in joint attention – the process in which an individual signals another to a stimulus via nonverbal means (e.g. gazing, pointing).
Whilst individuals with Asperger syndrome may have the ability to express themselves by employing age-appropriate vocabulary and grammar, it is common for them to display various peculiar language and related behaviour (Hallahan, Kauffman, & Pullen, 2014). They are often persistently and more severely impaired in the area of pragmatics, the rules surrounding the social use of language, compared to individuals with autism or PDD (Hallahan, Kauffman, & Pullen, 2014). These pragmatic problems apply to both verbal and nonverbal communication skills. For example, an individual with Asperger syndrome may not be skilled in the social concept of turn-taking, or they may fail to make eye contact with another person, often misconceived as lack of interest or approval in the conversation (Myles & Simpson, 2003; Hallahan, Kauffman, & Pullen, 2014).
3.4 Abnormal sensory perception
Some individuals with autism are either hyper-responsive or hypo-responsive to certain stimuli in their surroundings while others are argued to have a combination of the two (Hallahan, Kauffman, & Pullen, 2014). For example, some individuals with autism are over-sensitive to touch. Furthermore, several individuals with autism experience synaesthesia – the mixing of the senses (e.g. tasting shapes) and cognitive systems (Hallahan, Kauffman, & Pullen, 2014).
3.5 Impaired cognition
This essay would like to point out that perhaps the following characteristics displayed by individuals with autism should be considered different strengths or abilities in comparison to most of the general population rather than an impairment in cognition.
Like individuals with intellectual disabilities, many individuals with autism exhibit cognitive shortfalls (Hallahan, Kauffman, & Pullen, 2014). However, it has been suggested that there are certain cognitive processing issues that are specific to some individuals with autism (Hallahan, Kauffman, and Pullen, 2014). An example of this is that some individuals with autism process things visually and spatially as opposed to conceptually or linguistically, and this difference in favour of visual and spatial capabilities has since been coined thinking in pictures by Temple Grandin (Grandin, 2002, as cited in Hallahan, Kauffman, & Pullen, 2014).
At first glance, some individuals with autism are thought to be geniuses because of certain extraordinary skills that they display (Hallahan, Kauffman, & Pullen, 2014). These individuals are referred to as autistic savants – individuals that may have severe autism in regard to developmental delays of overall social and intellectual functioning, but at the same time these individuals exhibit noteworthy ability or talent in particular splinter skills (Hallahan, Kauffman, & Pullen, 2014). These splinter skills are argued to be intricately linked with autism, and appear to exist in isolation from the rest of these individuals’ abilities (Heaton & Wallace, 2004; Hallahan, Kauffman, & Pullen, 2014). Hallahan, Kauffman, and Pullen (2014) note that an individual may, for example, have extraordinary skills in playing music, but that, at the same time, that same individual may not have the functional mathematical capabilities to buy items in a supermarket.
With the general increase in autism awareness comes media attention, and autistic savants in particular are often covered by the media (Hallahan, Kauffman, & Pullen, 2014). But this attention, along with the use of autistic savants as protagonists in films such as Rain Man and Shine, has led to the misconception that most individuals with autism have these extraordinary talents (Hallahan, Kauffman, & Pullen, 2014). Although specific statistics are not apparent, estimates show that approximately 10% of individuals with autism are considered autistic savants (Hallahan, Kauffman, & Pullen, 2014).
4. Educational Implications
4.1 Educational Programming Principles
We can begin to see that the characteristics of ASD vary considerably, both in type and severity (Hallahan, Kauffman, & Pullen, 2014). Still, most researchers have come to the agreement that educational programming for students with ASD should include the following:
Direct instruction of skills. Literature on the effect of direct instruction (DI) on individuals with ASD has only emerged recently (Cadette et al., 2016). It is argued that effective instruction for students with ASD requires a highly organised, directive method which uses basic principles of behavioural psychology (Hallahan, Kauffman, & Pullen, 2014). One highly organised approach which focusses on teaching functional skills with continuous progress assessment in applied behaviour analysis (ABA). ABA is a comprehensive method which emphasizes positive reinforcement of wanted behaviour (Hallahan, Kauffman, & Pullen, 2014). Many professionals today avoid the use of punishment, which was an original consequence of undesired behaviour, suggesting that its implementation is ineffective (Hallahan, Kauffman, & Pullen, 2014). Overall, ABA has become the most widely studied psycho-educational intervention for individuals with ASD, and has produced a variety of potentially useful intervention techniques that could improve the functioning of these individuals (Smith, 2011).
DI through methods such as the ABA have recently been shown to be effective not just in the immediate implementation. For example, a study by Cadette and colleagues (2013) demonstrated that not only was the use of DI in the classroom effective in teaching primary school students how to answer “who” and “what” questions, but post-intervention follow-up assessments indicated that the students maintained these improvements 4-weeks later.
Instruction in natural environments. Educators of children with ASD are continuing to emphasize the importance of applying behavioural psychology in natural contexts and in natural exchanges, such as in the general classroom with children without disabilities (Hallahan, Kauffman, & Pullen, 2014). This area is again recent in regard to research, but a study Whalon and Hart (2010) on the experiences of primary school children with ASD during literacy activities in the general classroom highlights the important implications for inclusive education. This study found that collaboration between general and special educators is required in order for better instructional strategies relevant for students with ASD to be implemented in natural contexts and interactions (Whalon and Hart, 2010).
Behaviour management. It is recommended that a blend of functional behavioural assessment (FBA) and positive behavioural intervention and support (PBIS) be implemented in an attempt to reduce highly inappropriate behaviours (e.g. biting, screaming) which can sometimes be displayed in children with more severe levels of ASD (Hallahan, Kauffman, & Pullen, 2014). PBIS supports positive reinforcement, in that it requires finding ways to support positive behaviour exhibited by students rather than focussing on the punishment of negative behaviour (Hallahan, Kauffman, & Pullen, 2014). FBA focusses on the consequences (purpose of the behaviour), antecedents (triggers), and setting events (contextual factors) that sustain the inappropriate behaviours (Hallahan, Kauffman, & Pullen, 2014).
It is important to consider that no single programme is suitable for all individuals with ASD – deficits displayed by these individuals vary considerably in regard to severity and type (Hallahan, Kauffman, & Pullen, 2014). Due to this, educational methods tend to pay attention to a specific problem area for children with ASD. For example, for children with autism who have particular difficulty developing speech, educators can implement augmentative and alternative communication (AAC) systems such as the picture exchange communication system (PECS). PECS has been successfully implemented to help with the communication requirements of individuals with autism (Sulzer-Azaroff, Hoffman, Horton, Bondy, & Frost, 2009, as cited in Hallahan, Kauffman, & Pullen, 2014). This form of AAC enables individuals with no or restricted speech to use pictures to initiate requests and describe observations (Hallahan, Kauffman, & Pullen, 2014).
4.2 Early Intervention
Education and other associated interventions for individuals with autism need to be early, thorough, and highly organised and should involve (where possible) the family (Hallahan, Kauffman, & Pullen, 2014). Whilst there is yet to be a single intervention that provides evidence for widespread success in enabling children with ASD to overcome their disabilities entirely, early intensive behavioural intervention programmes are argued to have the ability to provide significant advances in many young children (Hallahan, Kauffman, & Pullen, 2014).
Early intensive behavioural intervention (EIBI) requires extensive time commitments from psychiatrists, parents, and the individual in applying highly organised training on separate skills (Hallahan, Kauffman, & Pullen, 2014). Whilst it has found to be effective in improving language and functional skills, researchers remain cautious in suggesting the use of EIBI due to the intense commitment (Hallahan, Kauffman, & Pullen, 2014).
Recently there has been a shift from EIBI to naturalistic approaches to early behavioural intervention (Schreibman & Ingersoll, 2011). Mentioned briefly above, this approach uses behavioural teaching strategies such as reinforcement, shaping and prompting to teach skills during child-directed activities (Schreibman & Ingersoll, 2011). Research has shown that teachers, parents, and peers have used this intervention strategy successfully, and that overall these interventions are particularly effective for increasing social communication skills in young children with ASD (Schreibman & Ingersoll, 2011).
5. Conclusions
This essay has only just scratched the surface of the wide range of literature surrounding ASD. From the first systematic descriptions in the 1940s, research and awareness of ASD has increased dramatically, and educational considerations and early interventions for children with ASD continue to develop and strengthen. Whilst ASD is considered a ‘disorder’, with words such as deficits and impairments often accompanying the characteristics exhibited by such individuals, this essay ends by asking readers to also consider the strengths possessed by individuals with ASD, and look to these in future when contemplating strategies to enhance the areas of functioning we believe these individuals are lacking in.
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