Childhood Autism Spectrum Disorder

Jessica Glass Kendorski, Amanda Guld Fisher

• Publisher: Momentum Press
• Year: 2017
• Print ISBN: 9781944749194
• eBook ISBN: 9781944749200
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

The research literature on intervention strategies for children with autism spectrum disorder (ASD) has mushroomed in the past 20 years. As the number of students diagnosed with ASD has grown, so has the number of professionals involved in developing and implementing effective treatment and educational practices. With this rapid expansion, it has become increasingly difficult to assimilate and utilize the varied range of strategies—encompassing behavioral, educational, ancillary or therapeutic. This volume provides a summary of these developments, including a historical review of the concept of autism as a diagnostic entity, and the lineage of the current best practice methodologies in assessment and intervention. The authors present concise and approachable information on the assessment and intervention of the characteristics of autism utilizing the science of applied behavior analysis.

CHAPTER 1

Description and Diagnosis

Autism Spectrum Disorder (ASD) is a diverse neurological disorder that presents during childhood. The complexity of this disorder, spectrum of characteristics and severity, combined with a large amount of unknown information, make for a complicated disorder to diagnose and treat. This chapter will discuss the current accepted diagnostic criteria, history, prevalence, and comorbidity, as well as some of the intricacies involved in this unique disorder.

Diagnosis

Autism Spectrum Disorder (ASD), as it is officially referred in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM 5; American Psychiatric Association [APA], 2013), has long been a disorder that science and society has sought to understand. ASD has an extensive history of varying diagnostic criteria, competing hypotheses of etiology, as well as controversy surrounding effective interventions. This history is likely due to the “spectrum” nature of ASD, where there are very different presentations of behavioral deficits and weaknesses at each end of the spectrum.

The hallmark behavioral presentations of ASD involve deficits in social and emotional communication as well as restricted, repetitive patterns of behavior. The DSM 5 outlines the diagnostic criteria and classification of psychiatric disorders recognized by the U.S. Healthcare System (APA, 2013). According to the DSM 5 diagnostic criteria for ASD, persistent deficits in social and emotional communication across a variety of contexts must be present. These deficits in social and emotional communication include:

1. Deficits in social and emotional reciprocity. For a child this may look like difficulty with typical reciprocal conversation, a failure to share emotions and feelings, and a failure to initiate and engage in social interaction. Specific examples of deficits in social and emotional reciprocity may include: failure to respond to name, failure to show objects to another, lack of shared enjoyment of activities, and talking “at” an individual rather than “to” an individual.

2. Deficits in nonverbal communication involved in social interaction. This may present as abnormal eye contact, difficulty with fluent nonverbal communication (e.g., a child may mimic the exact nonvocal communication of another rather than a natural matching of nonvocal responses), or a total lack of facial expressions or gestures to communicate. There may also be a mismatch between the verbal expression of the child and the nonverbal behaviors demonstrated. For example, a child may not show typical joy on face when happy or anger on face when upset.

3. Deficits in developing and maintaining relationships. This may look like a lack of interest in engaging with peers, difficulty initiating social interactions, and a lack of shared reciprocal play.

In addition to deficits in social and emotional communication, a child must also present with restricted or repetitive patterns of behavior interests or activities which can include:

1. Repetitive motor movements such as hand flapping and rocking, or repetitive speech such as repeating phrases or lines from videos or television shows.

2. Demonstration of rigid adherence to “sameness” and behavioral difficulty when routines are disrupted.

3. A highly restricted interest in a particular activity, object, or other interest. This is more than just a liking or interest, but rather a perseverative, obsessional focus on an activity or object.

4. Hypo or hypersensitivity to sensory input, specifically, sensitivity to different tactile stimulation on skin or in foods, sensitivity to loud noises, and seeking out different sensory activities such as staring at lights or excessive smelling of things.

These symptoms as outlined in the DSM 5 can vary their presentation in severity on a scale from 1 to 3. Level 1 is defined as requiring support, Level 2 is defined as requiring substantial support, and Level 3 is defined as requiring very substantial support. In addition to the previously referenced symptomatology, other criteria must be met to diagnose ASD, including, presentation of symptoms in early developmental period (birth to five years), presenting symptoms are not better explained by another diagnosis, and there must be a significant impairment in social, communication, and other areas of adaptive functioning (APA, 2013).

The International Statistical Classification of Diseases and Related Health Problems-10th Revision (ICD-10) is a medical classification by the World Health Organization (WHO, 1992). The ICD-10 outlines diagnostic criteria for disorders similar to ASD, although the disorders are not formerly named ASD. Rather, the ICD-10 classifies Childhood Autism, Atypical Autism, and Asperger Syndrome under the broader classification of Pervasive Developmental Disorders.

Childhood Autism is defined as the presence of impaired development before the age of three years; which includes deficits in three areas of reciprocal social interaction, communication, and restricted, repetitive patterns of behavior. This classification is very similar to the diagnostic criteria outlined in the DSM 5 (APA, 2013; WHO, 1992).

Atypical Autism is defined as atypical development that is present after three years of age, with a lack of impairment in the three areas required for a diagnosis of Childhood Autism. Although the full criteria for Childhood Autism is not met, there is typically a demonstration of deficits in one or two of the areas required for a diagnosis of Childhood Autism such as reciprocal social interaction or communication (WHO, 1992).

An additional “autism-like” classification present in the ICD-10 is Asperger Syndrome. Asperger Syndrome has similar characteristics to Childhood Autism, including deficits in reciprocal social interaction and repetitive stereotyped behaviors; however, a diagnosis of Asperger Syndrome does not require deficits in social communication. This is a major difference from the criteria in the DSM 5, as the most recent revision of the DSM removed the separate classification of Asperger Syndrome. According to DSM 5 criteria, a child presenting with deficits in reciprocal social interaction and repetitive stereotyped behaviors can still meet the criteria of ASD with the presence of typically developing verbal communication skills. This distinction in the United States was not without controversy. Those for the change argue that Asperger Syndrome falls on the spectrum of ASD; however, many families and children identified with Asperger Syndrome are concerned that removing the separate diagnosis may impact clinical service delivery and increase stigmatization (Halfon & Kuo, 2013).

History of Autism Diagnosis

The controversy surrounding Asperger’s Syndrome is part of a long history of changes leading to the current accepted diagnostic criteria of ASD. The history of the diagnosis is one where symptomatology necessary to be diagnosed with the disorder varied. Leo Kanner a child psychiatrist in Baltimore, MD was the first to describe what he called “autism” in 1943. He reported seeing children that he described as having a “persistent need for sameness,” as well as emotional and social withdrawal. These essential diagnostic features have remained a defining feature of the current diagnosis (Verhoeff, 2013). Throughout the years that followed, the core diagnostic characteristics of autism have changed with each newer edition of the DSM. Originally in DSM I (1952), the features of autism were defined under Childhood Schizophrenic Disorder, likewise, the revision to the DSM II (1968) defined Autistic as a subtype of Schizophrenia. It was not until the third edition of the DSM (1980) that there was the inclusion of “disorders of childhood” which outlined Autistic Disorder as a formal category under Pervasive Developmental Disorders. Finally, with the DSM 5 (2013) there was a renaming of Autistic Disorder to ASD and the current defining diagnostic categories adopted (APA, 2013).

Prevalence and Comorbidity

Since the year 2000, prevalence rates of ASD have been on an increasing trend. According to data from the Center for Disease Control and Prevention (CDC), in the year 2012 about 1 in 68 children have been identified with ASD in the United States. This represents a significant increase in prevalence rates of 1 in 150 in 2000, 1 in 125 in 2004, 1 in 110 in 2006, and 1 in 88 in 2008. Additionally, boys are 4.5 times more likely to be identified than girls, and white children are more likely to be diagnosed than African American and Hispanic children (Christensen et al., 2016). Globally, studies combining North America, Asia, and Europe estimate the prevalence of ASD at about 1 to 2 percent of the total population (APA, 2013). Additional prevalence trends in the United States from 2000 to 2012 indicate that ASD is more prevalent in families of higher socioeconomic status (SES) and in certain areas of the country such as New Jersey (National Academies of Sciences, Engineering, and Medicine, 2015).

The reasons behind the increase in the prevalence of ASD and whether it is still increasing remains a matter of debate. It is unclear if the increase in prevalence can be attributed to an increase in awareness, more specific diagnostic criteria, or a true increase in ASD (APA, 2013). Other factors that may contribute to the increase in prevalence include policies for screening during pediatric well visits, as well as changes in risk factors such as parental age, maternal obesity, and in vitro fertilization; however, these factors alone are unlikely to have contributed to the overall increase in prevalence (National Academies of Sciences, Engineering, and Medicine, 2015).

ASD tends to co-occur with several other disorders, most commonly intellectual disability (i.e., approximately 50 percent of individuals with ASD also have an intellectual disability) as well as various psychiatric disorders including social anxiety disorder, attention deficit hyperactivity disorder, and oppositional defiant disorder (Christensen et al., 2016; Simonoff et al., 2008). Additionally, there are a number of medical concerns that tend to occur in children with ASD, such as sleep disorders, gastrointestinal disorders, feeding disorders, and seizure disorders (Beauchaine & Hinshaw, 2013). Challenging behavior (e.g., aggression, self-injury) is often displayed by children with ASD. This can range from minor challenging behavior to severe behavior disorders. Due to the common presentation of comorbid medical, psychiatric, and behavioral concerns, comprehensive assessment and intervention should include all of these factors.

Early Identification and Diagnosis

Some signs and symptoms of ASD can occur as early as infancy. However, often the signs are not noticed until there becomes a wider developmental gap between the social and communication skills of the child in relation to his or her peers. This delay in diagnosis and intervention can have far-reaching implications. The earlier ASD is diagnosed and intervention is provided, the better social, emotional, and educational outcome for the child (Fernell, Eriksson, & Gillberg, 2013). The American Academy of Pediatrics (AAP) recommends that pediatricians screen children for ASD at 9, 18, and 24 and/or 30 months of age, and children with a positive screen receive a comprehensive evaluation (2016).

Recent research has identified some early behavioral signs of ASD to help aid in identification and intervention. One particular longitudinal study examined children at 6, 12, 18, 24, and 36 months of age. The findings indicated that at age 6 months, there were no real differences between children typically developing and those who later developed ASD; however, during the next 12 months those children eventually diagnosed with ASD demonstrated loss of skills, and declining social communication behavior (i.e., gaze to faces, shared smiles, and vocalizations; Ozonoff et al., 2010). In sum, these findings support the idea that there are symptoms of ASD as early as 12 months of age, and underscore the need for continued research into earlier behavioral markers that can aid in the identification of ASD.

A recurring theme in the research of ASD and public awareness campaigns is the concept of early intervention. In the United States as of 2012 the median age for a comprehensive evaluation was 40 months, with only approximately 43 percent of children receiving a comprehensive evaluation by 36 months. Additionally, most children in the United States were diagnosed at four years of age, two years after ASD can be reliably diagnosed (Christensen et al., 2016). To help support earlier identification, the CDC launched the Learn the Signs. Act Early public awareness campaign as well. Healthy People 2020 aimed to identify and evaluate at least 47 percent of children with ASD before 36 months. Research continues to support the effectiveness of early intensive intervention for children with ASD to the level that children are often found to be indistinguishable from same age peers after a few years of early intensive (25 to 40 hours per week) behavioral intervention (e.g., Lovaas, 1987; Jacobson, Mulick, & Green, 1998; Smith Eikeseth, Klevstrand & Lovaas, 1997; Smith & Lovaas, 1998; McEachin, Smith, & Lovaas, 1993).

Typical Development and Early Signs of ASD

The American Academy of Pediatrics recommends that all children are monitored and screened on their developmental milestones between the ages of birth to five years (Council on Children with Disabilities, 2006). The U.S. Department of Health and Human Services Birth to 5: Watch Me Thrive initiative is aimed at promoting behavioral and developmental screenings to assess language, social, and motor development, in an effort to identify and intervene early. Understanding typical developmental milestones can aid parents and caregivers in identifying the signs of ASD.

Often, children with ASD may demonstrate early signs of social differences that become more pronounced as they further develop. These differences can include a lack of eye contact, failure to respond to his or her name, failure to point and look at others while pointing, a lack of imitation, and a lack of appropriate facial expressions. A child with some of these characteristics may be described by parents as a “good baby” since the child may not necessarily seek out the parent for social interaction. Children with typical social development will spontaneously seek out the parent and want to share objects, items, and emotional experiences, known as shared enjoyment. This is often absent in a child showing signs of ASD.

There are also marked communication differences between a child developing typically and a child with ASD. Noticed first, is often a delay in receptive and expressive language development, specifically, not stating single words by 16 months of age, a lack of nonverbal communication such as gesturing or pointing, and not responding to the communication of others. At times, parents may report that their child is having hearing difficulty due to the child’s lack of response. In addition to delays in expressive and receptive language, there is likely a lack of initiation of communication, as well as reciprocal (back and forth) communication. For example, a child as young as 6 months will be able to communicate that they need help, by actively trying to...

Table of contents

• Cover
• Half-title Page
• Title Page
• Copyright
• Contents
• Acknowledgments
• Chapter 1 Description and Diagnosis
• Chapter 2 Conceptualization
• Chapter 3 Evaluation and Assessment
• Chapter 4 Treatment
• Chapter 5 Case Studies
• ASD Behavior Support Plan Checklist and Planning
• ASD Programming Checklist and Planning
• References
• About the Authors
• Index
• Backcover