Autism Spectrum Disorder in Children

Autism Spectrum Disorder is a developmental condition that begins in childhood and can persist into adolescence as well as adult hood. According to Brentani, Paula, Bordini, Rlim, Sato, Portolese & McCracken (2013), children with autism show autistic symptoms within the first one year of life. Others start to develop autism signs within 24 months. It is referred to as a “spectrum” disorder because it has a wide range of symptoms that vary among different individuals. Main features associated with this condition include repetitive behaviors and challenges with speech, communication and social interaction (Brentani et al., 2013). Epidemiological studies have revealed that Autism Spectrum Disorder (ASD) is a condition that is widespread across many countries (World Health Organization, 2017). Reports from the World Health Organization show that 1 in 160 children worldwide has autism. This figure is just an estimate of the prevalence rate of ASD globally as many studies report varying prevalence rates. Many epidemiological studies conducted over the last 5 decades indicate an increased prevalence of ASD globally (World Health Organization, 2017). In the United States, for example, recent reports from the Centers for Disease Control and Prevention (CDC) shows that the prevalence of ASD has increased by 15% from 1 in 68 in the year 2016 to 1 in 59 children this year (Autism Speaks, 2018). While there is no specific cure for ASD, early treatment through therapy and support systems could make a difference on the life of the affected person ( Zwaigenbaum, Bryson, Garon 2013) . The paper develops a treatment plan for a child diagnosed with ASD, taking into account the social and emotional development of the child. The paper discusses the causes, symptoms, screening and diagnosis of autism. Under the treatment interventions, the paper incorporates the 5Ps approach and describes the various treatment therapies that can help improve the social and emotional development of an autistic child. 

Causes and Symptoms of Autism 

Causes 

While there is no evidence of the single cause of Autism Spectrum Disorder, available data indicates that the disorder is caused by different causal factors including neurobiological, environmental and genetic factors that manifest through behavioral symptoms (Persico & Bourgeron, 2006). Experts believe that genetic factors play a critical role in the development of ASD in children (Geschwind, 2011). For some children, the disorder is linked to various genetic disorders like Rett syndrome. Evidence shows that children with Rett Syndrome (RTT) tend to lose speech and develop seizures and autism after 18 months of age (Amir Van den Veyver, Wan, Tran, Francke & Zoghbi, 1999). In other scenarios, gene mutations within the family may increase the risk of the disorder. This means that these genetic mutations can either be inherited. Infants or children with older siblings diagnosed with ASD are at high risk of developing the disorder. A child’s likelihood of developing autism is higher if there are more than one older siblings affected by the condition (Ozonoff et al., 2011). Due to the availability of gene sequencing tools and accessibility of DNA samples, many studies have identified genetic factors linked to autism (Coe, Girirajan & Eichler, 2012). 

According to Williams (2012), neurological factors associated with ASD include abnormal mechanisms in the development of the brain. These abnormalities can result in symptomatic behaviors, cognitive abnormalities, structural brain abnormalities and functional abnormalities of the brain. Neurological differences linked to autism include problems related to the development of the genetic code, including the temporal lobes (Abraham & Geschwind, 2010). Other neurological differences linked to ASD include the differences in how the brain responds to the surroundings. This includes reduced sensitivity to gaze shifts (Elsabbagh et al., 2012) and disruptions of the normal patterns of a child’s social neurodevelopment (Jones, Carr & Klin, 2008). 

On the issue of environmental factors associated with autism spectrum disorder, many researchers have sought to investigate how pre-natal and post-natal factors such as diet, medication use and exposure to air pollutants during pregnancy relate to increased susceptibility to autism (Landrigan, Lambertini & Birnbaum, 2012). Some of the environmental hazards that have currently been identified include insecticides, hydrocarbons, flame retardants, lead and vehicle emissions (Shelton, Hertz-Picciotto & Pessah, 2012). For many researchers, however, research on this area is complicated because they have to demonstrate how an environmental factor is linked to the genetic information of the affected person. 

Symptoms 

In general, the signs and symptoms of ASD may start appearing at early infancy (below three months) or within the first 1-2 years of life. In early infancy, children may present symptoms such disengaged visual attention and in deference to parents. Children aged 1-2 years may present signs such as early temperament and expressive and receptive language delay (Zwaigenbaum 2005). It is important to note that, irrespective of these symptomatic differences, common features associated with autism relate to impairments on social communication skills (Brentani et al., 2013). Core characteristics associated with ASD include repetitive behaviors, impairment of language skills and difficulties in social interaction, communication, cognitive skills, behavioral regulation as well as imaginative abilities. These features are influenced either by the severity of the condition or the child’s developmental level of acquiring language skills (Zwaigenbaum 2005). 

Children with ASD may present social communication problems relating to joint attention, social reciprocity and social cognition. Deficits related to joint attention include reduced shared attention, difficulties in considering the intentions of another person and difficulty orienting to other people. A core feature of ASD is social reciprocity (White, Keonig & Scahill 2007). Impairments related to social reciprocity include difficulties in interacting with other people and problems of turn-taking when interacting with others. Deficits associated with social cognition, therefore, include difficulties in managing interpersonal information and emotions (Payton et al., 2000), developing prosocial goals and differentiating people’s feelings (Moskowitz, 2005). Deficits related to cognitive skills include impairment of the cognitive processes associated with perception, understanding and the use of physical, auditory and visual cues. Repetitive behaviors associated with ASD include performing repetitive movements (stimming), echolalia, preoccupations with things, sensory issues and performing harmful activities (National Institute of Mental Health). 

Severity levels of ASD 

The Diagnostic and Statistical Manual, 5 th edition outlines the three severity levels of autism spectrum disorder that must be put into account when diagnosing the condition. The three levels include: level 1 (Requiring support), level 2 (Requiring substantial support) and level 3 (Requiring extensive substantial support). Children with level 1 ASD have social communication deficits that cause impairments that are easily noticeable. Such impairments include poor social skills, poor organization, inflexibility, difficulties switching between activities and reduced social interaction initiating difficulty. Children with level 2 ASD present marked challenges in verbal and non-verbal communication skills, limited social interaction, reduced responses to other people’s social overtures, restricted repetitive behaviors and behavioral inflexibility. It is important to note that children with level 2 ASD may present such features regardless of support from parents and caregivers. Children with level 3 ASD have severe difficulties in communication skills which causes severe functional impairments, limited intelligible speech, and rare initiation of interactions, extreme inflexibility of behavior and not being able to cope with changes and great distress. 

Assessment and Diagnosis of ASD 

Assessment 

Several assessment tools have been developed to address social and behavioral impairment in children with ASD. Common assessment tools that have been validated in many studies include the Social Responsiveness Scale (Hus, Bishop, Gotham, Huerta & Lord, 2012), Social Skills Rating System (Gresham & Elliot, 1990) and the Comprehensive Assessment for Spoken Language (CASL). 

Social Responsiveness Scale 

Social Responsiveness Scale (SRS) is an evidence-based assessment tool that is designed to measure the presence and the severity of the social impairments associated with ASD. Mostly used in research settings, the assessment tool is appropriate for measuring the social abilities of autistic patients aged between 4 and 8 years. The continuous measure provided by this assessment tool is ideal for identifying autistic children with mild or severe social impairments (Hus et al., 2012). It is also ideal for identifying non-ASD patients who present impairments in social skills. Apart from social impairments, the SRS also measures other core characteristics associated with autism, including repetitive behaviors and deficits in communication skills (Constantino et al., 2000). 

Social Skills Rating System 

According to Gresham & Elliot (1990), the Social Skills Rating System is an assessment tool that is commonly used by clinical experts to assess the social behavior of pre-school and elementary children. More specifically, it focuses on academic competence, problem behaviors and social skills in different social contexts. The assessment tools consists of questionnaire booklets for the educators, parents and the children being assessed. The administration time for the SRSS is dependent on the number of selected respondents and rating scales used for the assessment (Diperna & Volpe, 2005). Many psychometric studies conducted in different countries like Netherlands, US, UK, Slovakia and Norway have already employed this assessment tool and have proven that it is effective in identifying and evaluating the social skills of children with autism (Freitas & Del Prette, 2015). In fact, it is among the most studied assessment tool in the literature of social skills and more so, the most commonly used tool with elementary children (Matson & Wilkins, 2009). 

Comprehensive Assessment for Spoken Language 

The Comprehensive Assessment for Spoken Language (CASL) is an evidence-based assessment tool used by clinical experts to assess and evaluate the language skills of autistic children and adolescents. According to the Integrative Language Theory (ILT) established by Elizabeth Carrow-Woolfolk, spoken language is primarily based on an individual’s performance, structure, knowledge, comprehension and expression of language (Carrow-Woolfolk, 1999). The four categories of oral language assessed using this tool include pragmatic, syntactic, lexical and supralinguistic (Reichow, Salamack, Paul & Klin, 2008). 

Diagnosis based on DSM 5 Criteria 

American Psychiatric Association’s DSM 5 manual outlines the various symptoms associated with autistic behaviors and specifies the major signs that must be identified by the therapist to confirm that a child has ASD, hence requiring diagnosis. The manual also outlines the severity levels of the disorder. Health care professionals also need to conduct diagnostic assessments to find out whether or not a child has ASD. In general, the criterion for ASD diagnosis suggests that a child must present repetitive behaviors and deficits in social communication for him or her to be diagnosed with autism (Matson et al., 2012). Therefore, the criteria used for diagnosis is based on the various symptoms associated with repetitive behaviors and impairments in communication and social interaction. 

Based on the criteria, deficits in social interaction and communication in different social settings are exhibited through difficulties in social-emotional reciprocity, non-verbal communicative behaviors used when interacting with others and difficulties in starting and maintaining relationships with peers in different social contexts. The second criterion highlights how restricted repetitive behaviors associated with autism are manifested. According to the manual, repetitive behaviors are demonstrated by having repetitive motor movements, fixated interests with unusual objects and being hypo or hyperactivity to various environmental stimuli such as pain and temperature. The third criterion suggests that ASD symptoms must start appearing at the early stages of a child’s development for him or her to be diagnosed with the condition. 

Intervention and Management Plans for an Autistic Child 

The following therapeutic intervention plans will be addressed under this section; Cognitive Behavioral Therapy, Applied Behavioral Therapy, Speech Therapy, Joint attention therapy and Social Skills Group Therapy. This section also incorporates the 5Ps approach, describing how it can be as an intervention measure for the disorder in question. 

Cognitive Behavioral Therapy 

There is growing evidence showing that a majority of autistic children with social impairments also present social anxiety (White, Albano, Johnson, Kasari, Ollendick, Klin, Oswald & Scahill, 2010). When present, anxiety increases social impairment. Similarly, poor social functioning contributes to anxiety which can persist into adolescence or adulthood. Therefore, a therapeutic intervention that focuses on reduces anxiety helps to promote social development in an autistic child (White et al., 2010). Many clinical studies provide evidence on the effectiveness of modified Cognitive Behavioral Therapy in reducing anxiety and promoting social skills in children with ASD. Many reports, for instance, have highlighted improved self, help, social interaction and anxiety through CBT (Brentani et al., 2013). In many of these research studies, CBT approaches for addressing social deficits in autistic children have been modified to include enhanced predictability of the treatment components, increased involvements of parents and incorporation of visual aids (White et al., 2010). One strength of the CBT in relation to ASD treatment is that it can be delivered in different forms, individual, family or group CBT. One advantage of the individual CBT is that it helps to address the specific health needs of the patient, taking into account their values and interests. One advantage of the family CBT is that it increases parental involvement in changing the life of their autistic child and enables them to understand the various challenges facing the child (White et al., 2010). This intervention measure, however, has been criticized for increasing risks of bias (Weston, Hodgekins & Langdon, 2016). 

Applied Behavioral Analysis 

According to Brentani et al (2013), Applied Behavioral Analysis (ABA) is a learning and behavior-based therapy designed to improve specific behaviors such as non-verbal communication skills, reading and social skills in children with ASD. The operant learning techniques applied in this therapy include positive reinforcement (using praise to enhance desired behaviors), differential reinforcement (reinforcing a behavior that is acceptable socially), shaping (rewarding the child until he or she exhibits the desired behavior), punishment (subjecting the child to undesired stimulus in order to reduce problem behaviors), fading (reducing prompts in order to increase independence) and extinction which involves removing reinforcement to maintain a certain problem behavior (Brentani et al., 2013). Many research studies have shown effectiveness of ABA in enhancing language skills and communication skills, decreasing problem behaviors and improving social skills, attention and memory in autistic children, adolescents and adults (Brentani et al., 2013; Lindgren & Doobay, 2011). Specific ABA strategies that have been proven to be effective in promoting behavioral development in children with ASD include Discrete Trial Training (DTT), Pivotal Response Training (PRT) and Functional Communication Training (Lindgren & Doobay, 2011). One of the biggest strengths of the ABA is that it can be modified or improved to meet the needs of the autistic child undergoing treatment. Another strength is that the behavioral therapist can use it to treat patients of all ages, including children, adolescents and adults (Lindgren & Doobay, 2011). Another strength of the ABA model that makes it a preferred therapy by many psychologists is that its results are measureable and easily observable (Lindgren & Doobay, 2011). The greatest weakness of this therapy is that its application has a limited theoretical framework. Another weakness is that it does not really address impairments in the emotional skills of children with ASD (Lindgren & Doobay, 2011). 

Speech-Language Therapy 

Providing efficient communication opportunities is a key priority in promoting social development in child with ASD. According to Tamanaha, Chiari & Perissinoto (2015), Speech-Language Therapy is one of the most effective intervention measures that is widely used by Speech and language pathologists (SLPs) to address the communication and social impairments in children diagnosed with ASD. Other problems addressed by this therapy include difficulties in reading comprehension, expressing basic needs, following directions, limited speech and poor conversation skills as well as vocabulary development. Therefore the goal of the speech-language therapy is to help an autistic child develop reading, writing, early communication, turn-taking, conversation and listening skills among others (Tamanaha et al., 2015). One of the biggest strengths of this intervention measure is that it can be adjusted or modified to match the needs and abilities of the autistic child undergoing treatment (Tamanaha et al., 2015). The biggest drawback of this intervention measure is that it is time consuming in the sense that therapy sessions must be conducted throughout the week, hence placing added stress on the parents and therapist (Pascoe, Stackhouse & Wells, 2006 pg. 207). 

Social Skills Training (SST) 

According to White, Koenig & Scahill (2007), Social Skills Training is a child-specific intervention measure used to create small social groups and is aimed at training them how to interact freely and appropriately. It involves teaching specific skills through the use of behavioral and social learning approaches. According to Reichow & Volkmar (2010), engaging autistic children in social skills groups helps to develop conversational, interaction and emotion-regulation skills. Take, for instance, the group consists of children with difficulties in starting conversation. The facilitator of the group (therapist or teacher) can lead the children through various exercises that help them learn conversational skills, which includes starting and maintaining conversations with other people. One Strength of this intervention measure is that it provides an autistic child the opportunity to put into practice the newly learned skills, hence promoting social interaction skills (White, Koenig & Scahill, 2007). One major weakness associated with the SST is that the skills acquired by the patients cannot be generalized in different settings (Klin & Volkmar, 2000). 

Joint Attention Therapy 

According to a study conducted by Kasari, Gulsrud, Wong, Kwon and Locke, (2010), joint attention therapy is another therapeutic intervention that has been proven to be effective in social development of children with autism. The purpose of this particular study was to examine whether or not joint attention intervention would improve joint engagement between a caregiver and a toddler with ASD. The findings of the study revealed that joint attention therapy is effective in helping autistic children to improve their skills in pointing, showing and coordinating looks between people and objects (Kasari et al., 2010). The most significant benefit associated with joint attention therapy is that it allows parents to socialize with their autistic child as his or her attention improves (Kasari et al., 2010). The weakness of the therapy is that, although the results are observable, they are not measurable (Kasari et al., 2010). 

Preventative Intervention Measure: 5P’s Approach 

Many scholars have emphasized the need to have preventive intervention measures for autism in children. According to Miller (2010), 5Ps approach is one of the most effective intervention measures that can be used to prevent the reoccurrence of autistic behaviors in children who had previously been diagnosed with ASD. Used an a preventative intervention measure, the 5Ps Approach provides a structured framework that parents and health care professionals can use to address the needs of children with autism. Developed by Linder Miller, the approach focuses on managing behavior change, promoting independence and skill development through the 5Ps (Profiling, Prioritizing, Problem analysis, Problem solving and Planning). The technique uses green, amber and red colors to differentiate between various behavior levels and puts emphasis on the use of a different strategy for each level identified (Miller, 2010). The priority of this technique is to profile the patient to understand his or her needs and then developing an individualized plan (green zone) to meet the patient’s needs. The plan outlines the necessities for the patient and what should be done to maintain the green zone. Problem solving and analysis of the approach are used in the amber and red zones to determine why the patient behaves in a certain manner and identify the various factors influencing those behaviors (Miller, 2010). In the context of preventing and managing ASD, the 5Ps approach focuses on preventing future autistic events by implementing the intervention plan develop at the green zone (Miller, 2010). 

References  

Abrahams, B. S., & Geschwind, D. H. (2010). Connecting Genes to Brain in the autism spectrum Disorders. Archives of Neurology, 67 (4), 395–399. 

Amir, R. E., Van den Veyver, I. B., Wan, M., Tran, C. Q., Francke, U., & Zoghbi, H. Y. (1999). Rett syndrome is caused by mutations in X-linked MECP2, encoding methyl-CpG- binding protein 2. Nature genetics, 23 (2), 185. 

Autism Speaks. (2018, April 26). CDC increases estimate of autism’s prevalence by 15 percent, to 1 in 59 children. Retrieved from https://www.autismspeaks.org/science-news/cdc- increases-estimate-autisms-prevalence-15-percent-1-59-children 

Brentani, H., Paula, C. S. D., Bordini, D., Rolim, D., Sato, F., Portolese, J.,& McCracken, J. T. (2013). Autism spectrum disorders: an overview on diagnosis and treatment. Revista brasileira de psiquiatria, 35 , S62-S72. 

Carrow-Woolfolk, E. (1999). Comprehensive assessment of spoken language . Circle Pines, MN: American Guidance Service. 

Coe, B. P., Girirajan, S., & Eichler, E. E. (2012, May). The genetic variability and commonality of neurodevelopmental disease. In American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 160 (2), 118–129). 

Constantino, J. N., Przybeck, T., Friesen, D., & Todd, R. D. (2000). Reciprocal social behavior in children with and without pervasive developmental disorders. Journal of Developmental and Behavioral Pediatrics, 21 (1):2–11 

Diperna, J.C., & Volpe, R.J. (2005). Self-report on the Social Skills Rating System: Analysis of 

reliability and validity for an elementary sample. Psychology in the Schools, 42 (4), 345- 354. 

Elsabbagh, M., Mercure, E., Hudry, K., Chandler, S., Pasco, G., Charman, T., Johnson, M. H. (2012). Infant neural sensitivity to dynamic eye gaze is associated with later emerging autism. Current Biology, 22 (4), 338–342. 

Freitas, L. C., & Del Prette, Z. A. (2015). Social Skills Rating System-Brazilian version: New exploratory and confirmatory factorial analyses. Avances en Psicología Latinoamericana, 33 (1), 135-156. 

Geschwind, D. H. (2011). Genetics of autism spectrum disorders. Trends in cognitive sciences, 15 (9), 409-416. 

Gresham FM, Elliot SN (1990). Social Skills Rating System: Manual . Circle Pines, MN: American Guidance Service. 

Hus, V., Bishop, S., Gotham, K., Huerta, M., & Lord, C. (2012). Factors influencing scores on the social responsiveness scale. Journal of child psychology and psychiatry, and allied disciplines, 54 (2), 216-24. 

Jones, W., Carr, K., & Klin, A. (2008). Absence of preferential looking to the eyes of approaching adults predicts level of social disability in 2-year-old toddlers with autism spectrum disorder. Archives of General Psychiatry, 65 (8), 946. 

Landrigan, P. J., Lambertini, L., & Birnbaum, L. S. (2012). A research strategy to discover the environmental causes of autism and neurodevelopmental disabilities. Environmental Health Perspectives, 120 (7), a258–a260. 

Kasari, C., Gulsrud, A. C., Wong, C., Kwon, S., & Locke, J. (2010). Randomized controlled caregiver mediated joint engagement intervention for toddlers with autism. Journal of autism and developmental disorders, 40 (9), 1045-1056. 

Klin, A., & Volkmar, F. R. (2000). Treatment and intervention guidelines for individuals with Aspergers syndrome. In A. 

Klin, F. R. Volkmar, & S. S. Sparrow (Eds.), Asperger syndrome (pp. 340–366). New York: Guilford. 

Matson, J. L., Kozlowski, A. M., Hattier, M. A., Horovitz, M., & Sipes, M. (2012). ‘DSM-IV vs DSM-5 Diagnostic Criteria for Toddlers with Autism’. Developmental 

Neurorehabilitation, 15(3), 185-190. 

Matson, J. L., & Wilkins, J. (2009). Psychometric testing methods for children’s social skills. Research in Developmental Disabilities, 30 (2), 249-274. 

Miller, L. (2010). Practical behavior management solutions for children and teens with autism: The 5P approach. London: Jessica Kingsley Publishers. 

Moskowitz, G. B. (2005). Social cognition: Understanding self and others . New York, NY: Guilford Press. 

National Institute of Mental Health (n.d.) Autism Spectrum Disorder [online] available from 

< https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd/index.shtml > 

[20.11.2018] 

Ozonoff, S., Young, G. S., Carter, A., Messinger, D., Yirmiya, N., Zwaigenbaum, L.,Stone, W. L. (2011). ‘Recurrence Risk for Autism Spectrum Disorders: A Baby Siblings Research Consortium Study’ . Pediatrics 128(3), e448–e495. 

Pascoe, M., Stackhouse, J., & Wells, B. (2006). Persisting speech difficulties in children: Children's speech and literacy difficulties: book 3. Chichester, West Sussex, England: John Wiley & Sons. 

Payton, J. W., Wardlaw, D. M., Graczyk, P. A., Bloodworth, M. R., Tompsett, C. J., & Weissberg, R. P. (2000). ‘Social and emotional learning: A framework for promoting mental health and reducing risk behavior in children and youth’. Journal of School Health 70 (5), 179–185. 

Persico, A. M., & Bourgeron, T. (2006). Searching for ways out of the autism maze: genetic, epigenetic and environmental clues. Trends in neurosciences, 29 (7), 349-358. 

Reichow, B., & Volkmar, F. R. (2010). ‘Social skills interventions for individuals with autism: Evaluation for evidence-based practices within a best evidence synthesis framework’. Journal of autism and developmental disorders, 40(2), 149-166. 

Reichow, B., Salamack, S., Paul, R., & Klin, A. (2008). Pragmatic assessment in autism spectrum disorders. Communication Disorders Quarterly, 29 , 169–176. 

Tamanaha, A. C., Chiari, B. M., & Perissinoto, J. (2015). The efficacy of the speech and language. Revista CEFAC, 17 (2), 552-558. 

Weston, L., Hodgekins, J., & Langdon, P. E. (2016). Effectiveness of cognitive behavioural therapy with people who have autistic spectrum disorders: A systematic review and meta- analysis. Clinical Psychology Review, 49 , 41-54. 

White, S. W., Albano, A. M., Johnson, C. R., Kasari, C., Ollendick, T., Klin, A., Oswald, D. Scahill, L. (2010). Development of a cognitive-behavioral intervention program to treat anxiety and social deficits in teens with high-functioning autism. Clinical child and family psychology review, 13 (1), 77-90. 

White, S., Koenig, K & Scahill, L. (2007). ‘Social Skills Development in Children with Autism 

Spectrum Disorder:’ A Review of the Intervention Research, Journal of Autism And 

Development Disorders 37(10) 1858-1868 

Williams, D. (2012). ‘Neurological basis for autism: Implications for speech-language pathologists’. Miniseminar presented at the Ohio Speech-Language-Hearing Association, Columbus, OH . 

World Health Organization. (2017, April 4). Autism spectrum Disorders. Retrieved from http://www.who.int/news-room/fact-sheets/detail/autism-spectrum-disorders 

Zwaigenbaum L ,  Bryson S ,  Garon N . 2013. Early Identification of Autism Spectrum 

Disorders. Behav Brain Res [online] . Available from 

< https://www.ncbi.nlm.nih.gov/pubmed/23588272 > [16.11.2018] 

Zwaigenbaum, Lonnie & Bryson, Susan & Rogers, Tracey & Roberts, Wendy & Brian, Jessica 

& Szatmari, Peter. (2005). ‘Behavioral markers of autism in the first year of life’. 

International journal of developmental neuroscience: the official journal of the 

International Society for Developmental Neuroscience. 23. 143-52