Thursday, February 27, 2014

All the facts about autism



Autism:  Facts & Treatments

            As the mother of a child who was diagnosed with autism in 2006, I now recognize what a mysterious disorder this is to others.  It is a very complex disorder, and in those with a diagnosis of actual autism, it is a serious disability because it affects so many aspects of human development.  This paper explores the definition, causes, major treatments, and some of the myths surrounding autism.  The research is from highly reliable and respected experts in the field of autism such as Lyn Koegel, Temple Grandin (an autistic herself), The National Research Council on Autism, and The Neuropsychological Review Journal. It is a long paper, so you might want to scroll to the end for the “tips on how to communicate with the autistic child” if you are not that interested or in a hurry. The incidence of autism is now 1 in 110 (CDC, 2009).  A part of my job for the past 20 years has been teaching students how to write research papers.  Little did I know how much I would need this skill in my lifetime.  I wrote my first draft of this paper in spring, 2006, when I realized that my child had stopped looking into my eyes and that every wheeled toy we owned in the backyard was turned upside-down so that he could spin the wheels.  We hope that you enjoy this paper not only for its hard facts, but also for the humorous parent insights into our world as well.
            In the past decade, there has been much study and speculation on the recent boom
in the number of reported diagnoses of children with autism. Autism, a pervasive developmental disorder, is a congenital brain condition that can severely or mildly affect a person’s ability to communicate with others and to function normally in society and is often accompanied by varying levels of mental retardation and behavioral challenges. Hallmarks include a lack of motivation to communicate, a lack of eye contact, restricted interests and repetitive behaviors. Many of the behavior tendencies of autistic children are quite similar.  For example, lots of kids with autism like to shake their fingers (or strings, or people’s hair) in front of their faces for a sort of visual stimulation. Many mouth objects way past the typical mouthing years. Some have odd repetitive vocalizations or repeat certain words or phrases constantly. Most are not interested in typical toy play and need help with toy skills.  Many of them love to spin things (like Tommy).  Some like to spin themselves!  Some never stop moving (Tommy). Some tend to rock back and forth or bang their heads on things (some kids end up having to wear helmets) (sadly, some are self-injurious and even bite themselves); others can’t stand too much motion!  Many flap their hands. Many are unable to regulate their emotions (especially anxiety in new situations & places) or read the emotions of others.  They  can take ages to potty-train (they are famous for smearing), some like to tear things (like paper or play dough) to pieces and then sift them….they love sand, and pouring water repetitively. Many have difficulty with fine motor skills and so dislike using eating utensils, preferring to eat with their hands. They are visually distracted to the extreme, not seeing the forest for the trees. They don’t care what other kids think, so they do weird behaviors without even noticing stigmas.  They are extremely compelled to do their “repetitive behavior of the year…” at any possible moment. They have severe challenges with impulse control and often run away suddenly in public places. A study from the 70’s showed autistic subjects being instructed not to do their repetitive behaviors, then being shocked (on a grated floor) every time they did their repetitive behaviors. They didn’t stop. This is MUCH more complicated than dealing with an unruly child. Sometimes we just have to laugh and pray to the Good Lord that someone out there will laugh with us.  (No you did NOT just see my son stand calmly and pee directly into the pool; no he did not just take his gumball out of his mouth, kick it down the hallway and then put it back in his mouth…nor did he try to roll a box turtle like a ball…what? that naked kid on the tennis court?  Never seen him before in my life!! J)  Sometimes I do just want to yell to the skies, “OK people, I’ve given him 30 Time Outs, 3 spankings, 78 serious talks, and we’ve left the place 80 times.  YOU WANT A PIECE OF ME?  Think you can do better?  HAVE AT IT!”  But I never do.J 
            Thirty years ago, in fifty percent of autism cases, the autistic person never developed normal speech, and many never spoke at all. Because of their difficult behaviors, autistic children were much more likely to be confined to institutions than other disabled children. In the past ten years, with new approaches to treatment, especially the insistence of developmental pediatricians on early intervention (preferably before age three), the percentage of autistics who learn to speak normally is closer to sixty-five than fifty.  The current educational approaches to treatment for autism involve gently intrusive teaching methods that “snap” the autistic child out of his solitary world and require learning and participation with others. Unlike normally developing children, autistic children are not as motivated to imitate or communicate with their peers as other children are. In fact, many researchers see this lack of drive to imitate and be like others (or even notice others) as one of the largest hurdles of autism.  Siegel writes, “In many ways, the absence of imitation is probably one of the biggest learning handicaps of a developing child with autism.  There is SO MUCH he should be taking in via observation of others” (2003, p. 114). This also explains why one-on-one communication is key in early treatment and why they tend not to do as well in group learning settings. However, learning to play with other children must become part of their treatment at some point or their new communication skills have no meaning or use.  And like all of us, they need friends!!
The standard “prescription” for an autistic child is a learning program that includes at least 25 hours of “directed intervention” per week, usually in the form of special education, speech and occupational therapy, ABA therapy and DIR-Floortime.  According to Temple Grandin, (a high-functioning fifty-year-old autistic who has designed nearly one-third of the nation’s cattle-handling facilities and equipment) in her book Thinking in Pictures, “Several studies have shown that twenty to twenty-five hours a week of intensive treatment which required the child to constantly interact with his teacher was most effective”(1996, p.46).  Siegel’s research also supports this amount of time in intervention, saying that “larger reviews of numerous studies support the suggestion of no difference in outcome between children treated for 25 hours per week and those treated for 35 hours per week” (2003, p. 315). Finally, the National Research Council on Autism “strongly recommends that young children participate in a minimum of 25 hours per week of early intervention services.  These hours can include a combination of interventions focusing on behavioral, social and language development.” Most developmental pediatricians recommend an intervention that includes ABA therapy (planned lessons which emphasize one-on-one reward-based learning that will provide your child the repetition and organization he needs to gain more cognitive skills), special ed, speech therapy, occupational therapy (to develop motor skills, especially fine motor), and Floortime (relationship-based, FUN, child-lead communication therapy) Grandin gives hope for a good outcome by suggesting that in children who have reasonably good awareness of their environments and not too much mental retardation “Early intervention in a good program can enable about 50 percent of these autistic children to be enrolled in a normal first grade” (a quarter of those diagnosed) (1995, p. 49).  Regarding hours of intervention, Koegel, in her amazing book Overcoming Autism answers a parent’s question about  intervention time requirements with the response “every waking hour” keeping in mind that it need not always be formal—but the practice by parents of keeping the child engaged in learning interactions at home can and should greatly augment formal intervention.  If any parent with an autistic child spends time researching the various therapies and treatments, she will find one common denominator in the best outcome research studies of successful therapies: enormous amounts of time spent in communication and play with the child.  Another characteristic that the best outcome children have is that they managed to acquire some language skills early on, better cognitive abilities by age 5, and healthy emotional attachments to loved ones.
            However, although the early intervention will improve the outcome, obviously the severity of the autism and whether there is accompanying mental retardation also matters,
 and the symptoms may worsen or improve with age. “One of the perplexing things about autism is that it is almost impossible to predict which toddler will be high-functioning.  The severity of the symptoms at age two or three is often not correlated with the progress” (Grandin, 1996, p. 48).  Temple Grandin herself was nonverbal at age three and constantly rocked back and forth.  She had all the typical symptoms of autism: poor eye contact, a lack of (or abnormal) speech, the appearance of deafness, frequent tantrums and noncompliance, a preference for being alone, and inappropriate play with toys.  Other general symptoms include a lack of or late gesturing (after 20 months of age), a lack of pointing to share interest, and repetitive behaviors such as rocking, hand-flapping, wheel-spinning, etc. Grandin credits first and foremost her mother, her governess, and good educators for “pulling her out of her autistic world” and insisting that she participate in theirs.  She began speaking at age three and a half after a year of intensive speech therapy and participation in a special needs preschool.
            Mark and I have personally have witnessed the unpredictable outcomes that Grandin mentions regarding autistic toddlers. Two of our nephews were diagnosed with autism spectrum disorders around age three.  The older boy (diagnosed with autism) is now ten years old and was nearly nonverbal until around age 7. (He presently is beginning to speak in short phrases to express wants but is not at all “conversational”). We continue to hold high hopes for him.  Upon meeting him, it is absolutely clear that he is autistic by his complete self-isolation and lack of awareness of others as well as his many odd behaviors. The other (diagnosed with PDD-NOS) is now eight years old, has  good speech, reasonable interest in others, good play skills and is being mainstreamed in school in third grade. At first glance, one would not guess that he is autistic because his symptoms are so mild at this point.  In addition, one of my brother-in-laws is a fifty-year-old autistic man with the functioning and verbal skills of a four-year old.  My mother-in-law recalls the hope and positive messages she received from therapists and doctors when he was a toddler…but his deficits were too severe to overcome. And I feel for my in-laws, who did not have the same experience with public awareness of autism.  In fact, at that time, autism was blamed on the “refrigerator mother” theory of Bruno Bettlleheim, who was later proven to be a fraud.  My own son was diagnosed (September 11 will now have an additional stigma for me) with autistic disorder.  The developmental pediatrician predicted that with a lot of Floortime (her first recommendation) at home and a good intervention program, he might enter a regular Kindergarten.  Bottom line—she didn’t know and was not willing to put that prognosis in her written report because of the unpredictable nature of the disorder.  Parents must be prepared for the possibility of any outcome.  It is crucial for parents of autistic toddlers to join support groups and classes as early as possible. Other parents of autistic children can help and provide not only support but good (although varied and sometimes loony) advice.  And only these people can truly understand the mourning process and recovery that invariably accompany the diagnosis of their child.
Autism symptoms usually appear before age three, and most cases become evident around age two and a half.  Statistics have suggested that a large percentage of children with autism also have varying degrees of mental retardation (National Research Council, 2005), possibly because of immature development of the cerebellum, abnormal development of the amygdale (2009) and the limbic systems (which explains their love of moving objects such as fans, etc.) as well as “unusual” brain circuitry; in other words, the autistic brain is truly wired differently.  Unfortunately, recent post-mortem autopsy studies have revealed problems in the frontal lobes: too many neurons of small size (the average brain has fewer and they are larger) as well as incomplete layering of the hippocampus and problems in the corpus collosum which connects the right to left sides of the brain.  In lucky high-functioning autistics, the brain will compensate for weaknesses in some areas by strengthening others.  It is commonly suggested that Einstein, who didn’t speak until he was three and a half and spoke poorly until age nine, may have been autistic.  Temple Grandin is a perfect example in her amazing abilities to visualize the equipment she designs (Thinking in Pictures, 1996).  There is a spectrum of severity.  The highest functioning area on the autism spectrum (though it is not called or considered classic autism) is called Asperger’s Syndrome.  These children are highly verbal and often bright, but socially self-absorbed and may need social skills help as a primary intervention.  The next diagnosis is PDD-NOS, which means that the child did not qualify for a diagnosis of autism because he did not fulfill the DSMV diagnostic criteria of:  1. speech and language deficits 2. social/communication deficits AND 3. restricted interests and repetitive behaviors.
One difficulty for autistic toddlers (and their parents) is that because they are physically normal and often have good gross motor skills (though most are at risk for fine motor skills), it is initially difficult for others to recognize their condition.  The parents of these toddlers often face much criticism from people who consider them to be “worry warts”, etc. when the toddlers are quite young because many of the symptoms of autism don’t become evident until they are closer to five years of age. Many autistic kids often look totally normal as babies, sometimes even the first 2 years of life.  The latest study published in the Archives of Psychiatry suggest that the abnormal amygdale growth causes autism in the second year of life, explaining why so many of these children look “fine” for their first 2 years.  Statistics show that around 70% of cases do not become apparent until the second year of life.  Perhaps that might explain some of the heartbreak that parents of autistic kids go through as they deal with their shock and disappointment. Also, many people simply do not understand autism and its possible negative outcomes (requirement for lifelong care, for example), genetic risk, and the importance of early intervention in the face of clear symptoms.
The early “invisibility” of autism compounds the difficulties that the parents AND children go through as they seek help and intervention.  I often wonder how my friends would have reacted if Tommy had had Down’s Syndrome or cerebral palsy….people seem to be so much more sympathetic to disabilities that they can see.  I have several friends now who also parent autistic children who have felt similarly….that their friends didn’t really support them until the children were around 7 or 8 years old since by that time, when a child isn’t able to communicate and function ‘normally’, it’s very clear.  But it’s quite hard, what we have to go through up until our loved ones finally get it.
  Some subtle early symptoms that pediatricians look for these days include the inability to point (especially to show interest) and gesture early on or follow a parents point or gaze.(joint attention skills).  And of course, a lack of language. These days, they are able to diagnose children as young as 12 months!    
The genetics of autism are emerging, and promising pharmacogenomic treatments are likely to become available in the near future. My husband and I attended a seminar by an Emory geneticist who believes up to 15 genes (areas on those genes) could be involved in autism, and the severity of the case depends how many genes are involved.  He claimed that to get a diagnosis of autism, at least 2 genes must be involved.  These days with a diagnosis, they do a bloodwork test that actually tests for several chromosome problems.  Although there are many other suspicious sites on many other chromosomes (new discovery points to chromosome 2) and kids with verbal apraxia and autism often have mutations in chromosome 7 FOXP2), in the past several years, scientists have only managed to locate the 3-4 most common chromosomal abnormalities of autistics.  One is a duplication in a part of chromosome 15Q and the other is a deletion in a part of chromosome 22Q.  Apparently, 22Q deletion syndrome causes the brain to develop even more abnormally than in other types of autism and is associated with much poorer outcomes.  There is a website dedicated to a support group for parents of 22Q deletion children.  There are many other chromosomes associated with autism. The new genetic panel (called micro-array analysis-developed July 2007) identifies about 30% of cases of autism.  Another possible genetic cause for autism is Fragile X, a genetic disorder that causes mental retardation and often looks like autism at its onset.  Unfortunately, like the 22Q deletion syndrome, Fragile X is also associated with poor outcomes in that it also causes more severe neurological damage, getting worse as the child gets older as other genes are systematically “turned off”.  A wonderful development recently is that there is a clinical trial for a drug (created by geneticists and pharmacists)for kids with Fragile X that is going VERY WELL! MIT researchers have reversed Retts Syndrome (a female form of autism) in mice with another such drug!! There is a neurodevelopmental pediatrician at the Marcus Institute who now claims to be able to identify “12 types” of autism based on which chromosomal abnormalities appear to be involved. Some autistic children with particularly complex chromosomal syndromes cannot be cured by even the best intervention.  People with 22Q deletion, for example, tend to have more deficits no matter what the intervention is.
Sadly, there is still no “cure” for autism (we will be the first to let you know since Tommy is now enrolled in a CDC study by S.E.E.D. that is investigating the causes of autism!). Any claims of a “cure” are more likely to occur in a child diagnosed with PDD-NOS (which is why many well-known programs are more likely to welcome children with a less severe diagnosis.) Some of these children DO have good chances at being “normalized” according to a recent article in the Neuropsychology Review (December 2008, V. 18, #4)  It gives me joy to quote the following:
“Evidence suggests  between 3-25% of children diagnosed with autism spectrum disorders LOSE their diagnosis eventually.  Possible mechanisms for recovery include:
1.                                      Normalizing input by FORCING ATTENTION OUTWARD or enriching the environment. (shared attention/shared emotion/SHARED everything!)
2.                                      Promoting the reinforcement value of social stimuli (DIR-Floortime!)
3.                                      Preventing interfering behaviors. (redirect to acceptable ones!)
4.                                      MASS PRACTICE OF WEAK SKILLS. (ABA!)
5.                                      Reducing stress and stabilizing arousal. (Occupational Therapy/Sensory Integration Therapy/Exercise!)
“Predictors include:
1.                   Relatively high intelligence/no severe genetic syndromes/no mental retardation
2.                   RECEPTIVE LANGUAGE
3.                   verbal and motor imitation
4.                   motor development
5.                   diagnosis of PDD-NOS or Asperger’s Syndrome rather than autistic disorder
6.                   early diagnosis and intervention

*(mommy suggestions in parenthesis)

Back to the general symptoms of autism, the main problems for all autistics are sensory issues, especially auditory processing.  The brain of an autistic has difficulty processing sounds, and the degree of this difficulty may determine the severity of the case of autism (Grandin, 1996).  It is terribly important that the autistic child be spoken to often to practice “listening” and responding.  An obvious symptom at young ages is not
responding to your name (often repeatedly).  A noisy daycare in which the child is not addressed much is the worst possible place for an autistic toddler.  The auditory processing problem can increase to the point where it seems the toddler simply can’t hear his name being called—almost a use it or lose it scenario. Thus, an early intervention requires continuous efforts to communicate with the child, forcing him to hone his listening and auditory abilities. 
  The auditory issues also explain why many autistics have profound difficulties with communication—the reason is twofold.  The malfunctioning amygdala, which controls the emotional system, the ability to read faces and emotions, and the ability to share attention with others.  Apparently, the amygdala grows abnormally large within the first 2 years of life, severely affecting the child’s motivation to communicate (Archives of General Psychiatry, 2009). Many studies have suggested a ‘fight or flight’ tendency in the autistic brain due to its inability to distinguish friend from foe.  This may explain some of the anxiety toward new situations and people.  Secondly, it is extremely difficult to speak normally when you can’t process sounds properly. About 10% of autistics also have accompanying verbal apraxia, (Tommy received this as a second diagnosis in 2007, followed by a third diagnosis of hyperactivity disorder in 2009) which makes their pronunciation very unclear.  These young children require an enormous amount of extra help with their articulation on top of their language and communication problems.
  Other autistics also have visual processing problems, which is why many of them favor their peripheral vision—because they can see better out of the corner of their left eyes due to left brain deficits and faulty connections between the hemispheres. Many do visual stimulation behaviors such as staring at spinning objects. Nevertheless, because most autistics have visual systems which are far better than their auditory systems, it is important to incorporate visual aids in teaching and communicating with them as toddlers; in fact, some autistics learn to read much better than they can speak..
The sensory issues autistics face explain why most developmental pediatricians will recommend occupational therapy with a ‘sensory-based’ approach.  The idea is that the sensory needs must be met before the child can be organized, calmed, or stimulated
enough to conquer other milestones.  This would require observation of the child and the development of a sensory profile.  Is the child overreactive and hyper needing to be calmed?  Or underreactive and sluggish needing stimulation?  What sensory experiences does the child gravitate toward:  tactile (play dough, sand), gross motor movement (jumping, running, climbing), etc.  While at first OT may seem a little like hocus pocus, on further observation, you might notice that some children become MUCH more talkative in water, or on a horse, or after jumping on a trampoline.  You might notice that sifting sand calms a child who is overstimulated.  And these observations are so useful for any parent of any child.  Never underestimate the mind-body connection.  The recent studies that show brain function’s relation to the act of crawling as an infant are useful in demonstrating the importance of early motor movement to the brain.  And moving a child with motor problems through an action enough times can actually enable him to eventually master it himself.  It just takes an enormous amount of work.  Ask any special ed teacher.  However, sometimes the OTs get carried away doing ONLY sensory stuff!  Remember that most autistic kids have fine motor problems and will require a GREAT DEAL of help with even simple motor tasks.  It will take them much longer to dress themselves, become potty-trained, cut, write, etc. 
  Their sensory difficulties also partly explain the love of autistics for routine.  When your sensory systems are mixed up or overreactive, the world can be a noisy, confusing place; thus, a comfortable routine or repetitive behavior can help you maintain your calm. An interesting theory presented in Grandin’s book is that the timing of the onset of the sensory problems of autism may determine the outcome or severity; for example, she suggests that children with very early onset of the sensory problems may have more damage to the amygdala whereas in children whose sensory processing difficulties appear later, emotions are more intact but severe language difficulties still occur  (1996, p. 40).
Perhaps most difficult are the learning problems.  Children with autism have severe deficits in the areas of attention and motivation.  Most of you know a child with ADHD. Multiply that by 1000, add a possible dash of mental retardation,  subtract 5 gallons of motivation to learn like other children, subtract any effect that peer pressure could possibly have, and you might just begin to understand why children with autism are SOOOOO hard to teach.  They require enormous amounts of one-on-one to learn even the basics (due to their severe deficits in joint attention).  Most cannot sit to be read to and may need behavioral help to concentrate at all.  (Tommy loved books, thank goodness, up through age 2 and a half, and suddenly had an enormous joint attention regression…..which was and still is a very difficult thing).  It is a disability that includes communication, emotions, language, and learning.
            Recent years have demonstrated an enormous increase in autism diagnoses from
one in a thousand to one in one hundred fifty. Part of the controversy related to the extreme increase in diagnoses is that some parents and professionals believe that in the 1990’s when the CDC increased the number of required immunizations for children, they failed to do adequate research on the effects of the increased amounts of the preservative thimerosol (a mercury derivative) on infants’ brains.  Some believe that this preservative has caused the increase, though there is no decisive evidence on the case. In fact, the latest study done in Canada on more than 500,000 children showed an increase in autism after thimerosol was removed from vaccinations. Others think that the spike in autism diagnoses may be related to the fact that the definition of autism has been widened in the past decade to include five “autism-spectrum disorders”.  I tend to agree with the latter since I see many children at Tommy’s program who are verbal and social..  It turns out that PDD-NOS means that the child has not fulfilled the diagnostic criteria for autism and so they only have several of the symptoms.  Many of these children are almost indistinguishable from the general population.  And children with Asperger’s Syndrome would not have been diagnosed 20 years ago.  They would have been called “nerds”.
            Whatever the reasons for the increase, the important focuses are clear.  The scientific and professional communities, together with parents, must demand adequate research on environmental agents that may cause autism in genetically predisposed children. They also must research the effect that the new definition of autism has had on numbers diagnosed.  But perhaps most importantly of all, therapists, special educators, and developmental pediatricians need to educate parents on the best strategies to use in early intervention to help their children achieve the great gifts of emotional attachment shared interests with others, and speech and language skills. In addition to special education programs provided through states (many of them outstanding),other therapies are also available. Some seem quite contradictory, but with extensive education and practice, observation of additional therapy with professionals, and an understanding of what seems to work with each individual child, parents can not only choose appropriate professional help, but also incorporate communication strategies into their everyday lives with these children that can make an enormous difference in whether and how well they achieve communication skills. In her book, Helping Children with Autism Learn, Bryna Siegel points to research that shows direct links between parent involvement in treatment and positive outcomes.  She states that some parents have a gift for making their autistic child more aware of the environment and taking advantage of ‘learning moments’.  “Every moment becomes a teaching opportunity. They know how hard to push (just enough but not too much), so that learning and a lesson are not the same thing” (2003, p.445). It is a delicate balance since children with autism are extremely independent, impulsive, and generally noncompliant, causing much grief to parents and teachers who must constantly attempt to control the autistic child’s lack of impulse control.  Children with autism may not express as much curiosity in things around them, but “very responsive parents of children with autism are able to tune into a much fainter signal.”  Siegel also points out, “In a study we did of very high responders to very intensive early interventions, a common characteristic of the ‘most-improved’ kids was that they had parents who wouldn’t leave them alone”.  This means decreasing the amount of time they would spend spinning wheels or in repetitive behaviors and increasing the time spent on positive interactions, learning, and fun that is not related to the repetive behavior preferences, especially isolating behaviors, of the child.  These parents will generally be the ones who participate in parent-training courses, choose therapists very carefully, observe school programs where the child may be enrolled,  find bright college students to do DIR-Floortime, speech, OT and ABA with their children, cultivate peer-buddies who can help their children at school and pre-teach school assignments at home (p. 446).  These parents understand that “intervention” means that ALL the meaningfully engaged activities a child experiences count, not just those with paid therapists.  It is the activeness of the child’s mind that is important.  Siegel adds that “the problem for children with autism is that they tend not to fill “free” time very constructively, and so intentional teaching situations need to be contrived to create the texture of a diverse and mentally stimulating life” (p.445).
Available Treatments
There are many philosophies and approaches to treatment of communication disorders, so parents must educate themselves and observe what works best for their child in order to choose what will probably ultimately be a blend of several therapies to encourage speech in the child. All autism interventions require speech and occupational therapy in addition to special education programs that concentrate on speech and play skills. Also crucial in autism interventions are Applied Behavioral Analysis (the most empirically supported intervention for children with autism to date), Floortime, and TEACHH (used in schools).  Some favorites of ours are Pivotal Response Training (a type of ABA training which is done in the child’s natural environment and involves the use of natural reinforcers), incidental learning techniques, Floortime, and ABA.  One of the greatest failures, in my opinion, in autism treatment, has been the failure of autism programs to address the emotional deficits of autism in their treatment.  These children need to be pulled in emotionally to our world.  They need to be taught to read the emotions of others, to empathize, to show interest in others….to look into our eyes and see what we feel. 
Early intervention, particularly one-on-one (since autistic kids have nonexistent attention spans) is crucial.  Scientific research has proven that although the brain has incredible plasticity, and in some areas, can grow and change throughout life, there are still “windows” of opportunity for various skills, and the speech window is age five. Language can still develop throughout life, especially Wernicke’s area of the brain, which involves receptive vocabulary. In addition, some studies show resilience in the speech structures through age ten, but most developmental pediatricians agree that the first three to four years of a child’s life are crucial language years for Broca’s area of the brain, which is used to produce speech.  Thus, the hard decisions about therapy are made in hopes that the early intervention will have the hoped for consequence.  “My child will be among the sixty-five percent that speak, and NOT the thirty-five that do not.” It is so important to remember that everything you do (and everyone does) counts! Research shows that everyday interactions can change and improve the brain structure of a
child (Greenspan, 1998).  An autistic brain may have weak circuitry between intent (affect and emotion) and purposeful speech and communication with others. Seek to strengthen those circuits by showing the child that playing, talking, and being with others can be fun and rewarding.  Perhaps those neurons and synapses which by age four are somewhat soldered in Broca’s area have a better chance to develop speech as well as creativity if the child is involved in bright, spontaneous, joyous interaction during playtime as much as possible. Greenspan suggests that traditional ABA Therapy, while it is helpful in training autistic children in basic skills and knowledge, may not be useful in the area of building relationships and encouraging spontaneous communication, which according to the National Research Council should be the number one intervention priority for young children with autism.  However, ABA has been proven effective in numerous studies in developing cognitive and adaptive skills and in reducing problem behaviors. ABA also may also be effective in developing functional communication (building vocabulary, for example)! It is an extremely valuable tool in the “intervention tool chest” and is highly recommended for at least 10 hours per week as part of the required 25 hours, as long as the work in joint attention skills is positive and emotionally rewarding for the child.    
            .  Another important point about intervention for autism is that though prescribes spontaneous interactions, insistence for responses (given with good will in a positive tone) is still a necessary element.  If your child does not answer your question, ask it again, simplify it, push gently for a response.  Do whatever it takes to close that
circle of communication.  As your child learns that responses are expected of her, she will become more attuned to the needs and initiations of others and able to participate in conversations.  Many parents unconsciously do what is easiest for their special needs child (not require responses, ask only yes/no questions, rely on rote word play (ready, set, _____) to extract speech.)  Some parents just give up.  It is so hard when they are young and won’t even turn around when you shout their name 8 times. You feel such grief and such intense worry….but you have to keep trying to get their attention.  And they won’t play with other kids so guess what?  You HAVE to keep playing with them.  And sometimes you will find yourself doing weird things WITH them to get their attention (you will steal their spinner and spin it) and it works!  You’ll get a smile!  You’ll keep trying.  And if you’re lucky, the day will come when he will turn to you with a smile only the 3rd time you call his name J  You will imitate him, make him notice you are having even more fun than he is sifting dirt!  He will decide you are alright.  And low and behold, he will WANT to play with you!
Another important concept presented by many interventionists is doing activities with your child that require use of many senses at once (to help integrate the use of all of them since autistic are noted to use only one part of their brains at a time (not multi-taskers, to be sure, kind of like men).  They do call autism the “extreme male” disorder.
Home Time
            In her book, Overcoming Autism,  Koegel also reminds parents that they can be
extremely effective additional “therapists” in the lives of their autistic children due, of course, to parents’ unsurpassed motivation, love, and desire to communicate with and help the child. However, it does require persistence, time, research, preferably some parent classes or instruction by speech and occupational therapists, and a lot of just plain the hardest work you will EVER do in your life.  Most people don’t have a clue how difficult it is to get the attention of these children.  Koegel also explains that “interactive therapy” need not always require a lesson plan.  Try to get your child help with the laundry and talk about the clothes and colors.  Discuss lunch while you make it together.  Pull weeds, water the flowers, wash the car.  Gently persist in getting your child’s attention to complete tasks together, like feeding the dog, loading the dishwasher, etc.  Your whole day should not have to revolve around the “therapy”, and your child needs to experience the world of the whole family—not be placed at the center of everyone’s universe and activities. Also, do not fail to teach survival skills and good manners.  By doing everything FOR a special needs child, you only handicap that child  further, well-defined in Koegel’s descriptions of “learned helplessness”, which is the sad fate of so many special needs kids.  Try to keep up as best you can with what is expected of her age group and be sure to use discipline (though you will probably need help from a board-certified behavior analyst for advice on what will work) for unacceptable behavior  because autistic children’s repetitive tendencies tend to make behaviors VERY hard to decrease and overcome.  It is something you will probably need professional help with during your experience raising your child.  (and relief and help for yourself should definitely be a part of it!).
Also, the importance of the child’s family and close friends cannot be overstated—each and every person that takes a loving role in her life can be a part of what motivates her to communicate more and more.  Reach out and bring people into her life as much as possible, and help them know how to better communicate with her.  Treatment providers must remember that the emotional deficits which accompany autism require greater effort in “connecting” with them, and is of crucial importance in every setting.
 Also, consider providing an environment rich in sensory experiences to your child.  Early childhood educators stress the importance of touch so much—let your child dig in the dirt, play with play dough, sand, and as many textures as possible.  Expose your child to the swimming pool-there is a reason why water therapy is so popular these days….it wakes children up and helps them speak and express themselves!  And swing, swing, swing!  Also, according to Time (May 2006), most autistics experience a great deal of anxiety, so for health and emotional reasons, vigorous exercise is recommended several times a day.  Jumping on beds or trampolines, running and hiking, dancing.. On the same note, many autistics find relief in deep pressure. Grandin went to the lengths of designing a “squeeze machine” for herself in which she could apply deep pressure to her entire body.  Some special education teachers keep a large bean bag in classrooms to “squish” the autistic children in.  Deep, strong hugs from a parent can go a long way.  Some occupational therapists recommend Auditory Integration Therapy, which is basically music which is modulated to stimulate the brain and supposedly can help with auditory processing problems.  Grandin states that the research support is minimal for this therapy; nevertheless, with all the studies that show how music enhances brain function, why not provide your child with many sorts of interesting music? In case of auditory oversensitivity, Grandin insists that the child should control the volume (1996).  Another goal should be to increase the variety of activities your child can enjoy and enhance her play skills by teaching her how to operate a continuous variety of toys, big and small.  This can help to develop her fine and gross motor skills in fun ways and have more activities that she can participate in with other children.
 Tips for Family & Friends
Build on the positive and join him in what he CAN do!!  And follow HIS lead sometimes!!  Tommy can swim, kick balls, make basic requests for items and actions, love, smile, laugh, ride a bike, hike, climb, run, jump on trampolines, toast his own waffle, spin anything, play on playground equipment, feed the dog, etc. Get face-to-face with the child to communicate and get her attention before trying to speak to her.  She may not respond or hear you otherwise.  Also, don’t insist on hugs and try to let the child take the lead in that area.  It might be wise to start with high fives and work your way up to hugs, but get there if you can!!  Try to use visual aids in your communication when possible.  Speak a little more slowly than normal and avoid strings of complex sentences unless you are simply telling her about something but not expecting responses.  Speak in words & phrases that the child can imitate or respond to and speak about the present! Put your activities in music and words; music is a right-brained activity, and autistic kids are more right-brained. If the child doesn’t answer a question, ask it again in a sing-song voice or try to regain her attention by singing, “Where is Jenny, where is Jenny?” (to the tune of “Are You Sleeping” for example). Use prompts like “Ready, Set, ______” before beginning an activity.  Always offer choices between 2 or 3 items and withhold the item until the choice is made. Offering the most attractive choice first helps the child to think more.  Many autistic kids are echolalic and will just repeat the last word they hear, so if you put the better choice first, it forces them to break this habit and think more about the choice. Withhold toys and activities until words are provided for the activity, even if it is just an incoherent ‘yes’!  Support the parents by NOT providing an object that the child will do repetitive behaviors with if it is clear that they are not providing that item at the time. Encourage turn-taking activities.  Many research studies suggest that turn-taking can positively affect brain-development and improve social interaction in kids with autism. Encourage eye contact in positive ways (and don’t allow anyone to do it in a negative way, for example, say, “Look at me!!” enthusiastically and then do something she will like, or give her something she will like. Tell her how much you love it when she looks into your eyes.  Gently say, “Look into Soren’s blue eyes and tell him By by” to try to get your child to have eye contact with others.  Physical horse play is a big deal for kids with autism who are unable to speak and understand you yet, but want to communicate. This will get the laughter, the eye contact, and the connection you are after until language and/or comprehension arrive. Another standard is playful obstruction-if the child is performing a solitary repetitive behavior, redirect or block it in a fun way (provide a fun alternative immediately to avoid tantrums. Count to 10 while waiting for answers.  With auditory processing delays, some autistic kids just need more time to answer a question.  Wait awhile before asking again. Most of all, be fun.  Be a part of the reason the child wants to try harder to communicate.    And when you can, just chat with her as you would a friend.  As one of my special educator friends explains, many of these kids can’t express themselves, but they can hear you, and you might be surprised at how much they hear!  So make it interesting and keep trying, for her sake.
Demonstrate and engage in as much pretend play as possible.  It is recommended to help children with autism develop abstract thinking skills, and it is an area of deficit for them.
Conclusion & Summary
Educate yourself on all the available therapies and be proactive.  Search for the most effective special education programs & teachers in your area.  There are many special education teachers with years of experience who are adept at not only the science but also the art of developing communication and play skills in special needs children. 
Thank your child’s teachers on a regular basis.  There is no field more difficult and no people more dedicated than special educators of all kinds.  Participate firmly in your child’s IEP process by providing objectives (along with the rest of the IEP team) that will be reachable and meaningful for her in ALL settings over the school year. The National Research Council’s book Educating Children with Autism is a fantastic resource for parents and schools regarding programs and goals.  And follow your instincts.
Good reports of ABA (Applied Behavioral Analysis) abound, especially for ‘kickstarting’ language, expanding vocabulary quickly, and teaching skills of all sorts.  ABA can also aid in retaining the child’s attention (critical skill) and expanding his cognitive abilities.  It may not speed up spontaneous language (the real problem for autistics) unless you have a truly excellent therapist, but it seems that staying abreast cognitively would certainly help them socially in the long run. In fact, the major weakness of behavioral programs has been their over attention to behavior and their lack of attention to spontaneous functional language -- which is the number one goal for young children with autism, according to the National Research Council.  Most would agree that another major weakness in traditional behavioral approached is that the emotional deficits and withdrawal that often accompany autism are not treated, or indeed even acknowledged.  Only in Pivotal Response ABA-in which affect scales are used to make sure that the children are happy and engaged-(used at Walden at Emory in Atlanta)and.  In other words, the treatment providers fail to have normal conversations and relationships with the children…follow their lead, build their motivation to communicate, or make positive affect and emotional engagement a part of the teaching procedures.  They simply don’t play with the kids!!!  So DIR-Floortime or Pivotal Response ABA should be large parts of the child’s treatment.
 Moderate amounts of ABA can only help, though some experts believe that too much table-top ABA (40-hour week regiments, for example) contributes to behavior problems, especially if the therapists improperly address the emotional deficits and fear of eye contact that must be treated carefully to build the child’s motivation to communicate with others.  Anyone who has seen a traditional ABA therapist say in a stern voice to a child with autism, “Look at me!!” and seen the fear and unhappiness on the child’s face will think very carefully about the ABA therapist they choose and their methods of teaching.
Ultimately, research has shown natural learning experiences generalize better (Pivotal Response ABA & incidental learning), but are more time-consuming and difficult to execute.  The great teachers will learn how to bring out joy and the desire to communicate in their autistic students, not just “fix behavior.”
 Although special needs children may not always have the outcomes parents hope for, the past decade of change in treatments has definitely made a positive difference; especially the insistence on early intervention, which pediatricians used to be loath to recommend.  The let’s wait and see until he’s three attitude has not paid off for those diagnosed in the long run, and if there are warning signs and a genetic history in the family, the earlier the  better is the new anthem among professionals.  Prepare yourself.  These early years of extra help will benefit your child, and she will not even remember them!  If appropriate therapies are given with love, good will, and a gleam in the eye, who knows what the future might hold for your very special child!!      
Now, after 3 years of coming to understand and accept Tommy for who he is, we can tell you, it is not an easy journey, but we can tell you also, there is no one we would rather take it with than him.  There is so much fun to be had and so much love in that heart. God provides amazing compensations.  Those blue eyes see the world in a very different way, and as hard as we all may try to educate him to be “one of us”, he will always also be a kind of angel, a little apart from the rest of us, not a malicious bone in his body, full of mischief and joy to last a lifetime.  Thanks so much for your time!!                                                              References
Grandin, T.  (1996).  Thinking in Pictures.  Random House Inc.  New York, New York
Greenspan, S.I. & Wieder, S. (1998).  The Child with Special Needs. Da Capo Press.
Koegel, L.K. (200 ).  Overcoming Autism. 
Moor, J. (2002). Playing, Laughing and Learning with Children on the Autism Spectrum.
            Jessica Kingsley Publishers, London & Philadelphia.
National Research Council. (2005). Educating Children with Autism.  National Academy Press.  Washington, D.C.
Piven, J.  (May, 2009).  Archives of General Psychiatry.  Research Study
Siegel, B.  (2003).  Helping Children with Autism Learn. Oxford University Press.  New       York,  New York.
Wallis, C.  (2006, May 15). New insights into the hidden world of autism.  Time           Magazine


           


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