Each month, this site will present information for educators, parents and researchers on emerging issues and developments in the field of children's mental health, especially those issues affecting the clients the Andrus Children's Center serves. Please email us with hot-topic requests or feedback at ACLI@jdam.org.

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April 2005: Understanding Children with Autism
Q: What is Autism?

Autism falls under the group of developmental disorders known as Autistic spectrum disorders (ASD). It is estimated that between 2 and 6 per 1000 children have ASD. The major symptoms of ASD include deficits and developmental delays in the areas of 1. social interaction, 2. verbal and nonverbal communication, and 3. repetitive behaviors and interests. These symptoms are present in individual children in very different ways and in different levels of severity. The types or subcategories of ASDs vary according to what symptoms are present, their severity, and when symptoms start.

The five diagnostic subcategories of ASD's given in the DSM-IV are: 1. autistic disorder 2. pervasive developmental disorder - not otherwise specified (PDD-NOS) 3. Asperger's disorder
4. Rett's disorder 5. childhood disintegrative disorder

Q: What causes Autism?
Some scientists believe that autism stems from a combination of genetic and environmental factors. Although there is still much ambiguity regarding the causes of the disorder, scientists have recently begun to gain a better understanding of how the disorder affects the brain. The brains of children with ASD develop differently than non-ASD children. For children with ASD, some parts of the brain have more connections than normal and others less. (1) Due to differences in how the brain is connected, parts of the brain are not able to work together as comprehensively as in a normal brain.

Q: How does Autism exhibit itself in children and affect
their development?
As children with ASD grow older, they communicate and interact differently than non-ASD children and often exhibit different behaviors. Early detection of the disorder is important although often difficult. In many cases, problems with interaction, along with other developmental issues, become more apparent among more high functioning ASD youth when they get older. The symptoms of higher functioning children sometimes only become apparent in the later grades of elementary school or middle school as they have difficulty in interacting with other youth, fitting into social networks and are ostracized and bullied. Generally the sooner a child with the disorder is able to receive treatment, the better the treatment outcomes. (2)

Communication and Social Interaction
A common symptom of ASD is "the delay or impairment in the ability to produce and respond to language." (3) Sometimes children with ASD do not develop speech and often the tone of children who are able to produce speech is flat and unexpressive. About 50 percent of children with autism (the more severe form of ASD) are functionally mute. (4) For many of those children with autism who are able to speak, their speech is limited to simple responses and expressions of desire.

Children with ASD have difficulty in making friends and making emotional connections with others. They also do not seek affection in common ways and often resist being cuddled or kissed. This is not to say that children with ASD do not feel emotion or are unable to have connections with others, only that they typically express emotion and form relationships differently.

Personal interaction is often challenging for children with ASD. Children with ASD typically have trouble understanding the meaning of other's facial expressions and displays of emotion or in maintaining eye contact. They also have great difficulty understanding the subtleties of personal interactions like humor and white lies and are more comfortable in highly structured situations with clear rules and consistent behavior. Children with ASD, even those with above average I.Q.'s, often must be taught how to have a conversation and to ask questions of others. Engaging in social interactions can be extremely difficult and frustrating for these children.

Among children with ASD, developmental delays and deficiencies in communication and social interaction can lead to other developmental problems. Research shows that children learn about the world through exploring, communicating and interacting with it. Therefore the problems children with ASD have with communication and interaction further compound their developmental issues.

Behaviors
Children with ASD also show little interest in imaginative play and are often more interested in repetitive acts. This focus on repetition might be exhibited in behavior like rocking or head banging (5) or in repetitive play like rolling a ball back in forth.(6) Children with ASD may feel comfortable with the same games every day and can struggle with having their routine changed or may become frustrated when things do not go there way. Children with ASD also sometimes have a large reaction to sensory stimuli, like a loud noise.

Q: What are some treatments for children with Autism?
ASD is not curable, however treatment is available and as scientists and care providers better understand the disorder, more and better information is available regarding which treatments are being proven to be most effective. Because of the complexity of the disease and the number of different types of ways to address it (e.g. various forms of therapy, education, and medical treatments) understanding and addressing the disorder can be overwhelming for parents and caregivers. Also, children with ASD often respond very differently to various forms of treatment often making the task of finding the right treatment for a child very difficult.

There are two general treatment approaches to ASD- focal treatments and comprehensive treatments. Focal treatments are directed at treating specific symptoms and areas of need like difficulty in interacting with other children. Comprehensive treatments, as the name implies, are more general, and provide a large scope of treatments in order to improve the general level of functioning of children with ASD. There is less information regarding the effectiveness of comprehensive treatments than focal treatments. (7)

Regardless of the treatment method that is used, parental involvement in essential. Parents can have a strong influence on treatment. Research has found that parent encouragement of play and communication is associated with significant improvement in language skills among ASD children. It is also important that parents are educated about the disorder and how it affects their children. Programs that educate parents about autism have been shown to be related to improvements in children's disabilities. (8)

An important part of the treatment process for ASD children is the identification and the monitoring of goals related to the behavior and development of ASD children. Such goals might include, establishing a regular toilet routine or increasing the ability to make needs known. It is important that parents participate actively in identifying intervention goals for ASD children. (9) Such involvement has been found to be clinically useful, especially in ensuring consistent and effective approaches to goals and treatment in the home and in school and for providing and sharing of ideas and knowledge.

In teaching children with ASD it is important to be aware of their strengths and deficits. ASD children understand and are sometimes obsessed with details and repetitive tasks but are unable to conceive of larger unifying concepts and understand how different pieces are tied together and are unable to participate actively in their environment. An important focus of treatment is therefore focusing on building skills and working to help children interact more closely with others and their environment. Also, teaching children how to interact with others can have an impact on their success in school.

One way to address problems with conversation among children with ASD and to help them interact better with other children is through the use of a structured format that capitalizes on their strengths is through the use of pre-determined scripts. Scripts help children with ASD understand how to engage others in conversation and to learn through role play and positive reinforcement. For example, a child is given a role in a play situation such as a worker in a carnival. (10) A loosely structured script is presented to and modeled for the child- things that one might say in that situation. The teacher then role-plays the situation with the child. Other similar methods for teaching conversation to children with ASD include the use of written scripts for children. Children are given written scripts, which include statements for initiating play and dialogue with other children. For example, one might be, "Do you want to play on the swing outside?" Children are asked to read the statements and to check off each one after it had been said, and after some repetition, the script is faded out, word by word. Another similar method uses video scripts. Children read and practice a conversational script on topics such as toys and books. The children then view the conversations they had practiced on a video. These and other methods using scripts have proven to be effective in teaching children to have conversations, interact, and play with other children.

The best supported type of focal treatment therapy for children with ASD is behavioral therapy (11) and there is limited evidence regarding the effectiveness of a specific type of behavioral therapy- Applied Behavior Analysis therapy (ABA). Behavioral therapy has been shown to be effective in influencing developmental problems connected to the disorder like speech problems and problems interacting with other children when applied intensively (at least 20 hours a week), over an extended period of time (one to two years), and when applied in a way that accounts for individual differences in children. (12) There is also evidence that it can positively influence language functioning and can lead to higher nonverbal IQ scores. (13) ABA is a repetitive form of treatment that is focused on building social and language skills through a highly structured process presentation of stimuli and direct feedback in the forms of reward. (14) Data collection and continual reinforcement are also important components. The Surgeon General of the United States concluded that ABA is the most effective way to treat ASD and is the only treatment that has been found to lead to "consistent improvements with autistic children." (15)

Along with ABA, other more recently developed therapies for children in the spectrum such as Floortime, RDI, and PECS also appear promising. See below for links to information regarding these and other autism therapies.

Sources:
(1) Sandra Blakeslee, "Focus Narrows in Search for Autism's Cause," The New York Times, February 8, 2005. Observed online on March 24, 2005 at: http://www.nytimes.com/pages/health/healthspecial2/

(2) John O'Neil, "One Boy's Journey Out of Autism's Grasp," The New York Times, December 29, 2004. Observed online on March 24, 2005 at: http://www.nytimes.com/pages/health/healthspecial2/

(3) Alexis Ann Schoen, "What Potential Does the Applied Behavior Analysis Approach Have for the Treatment of Children and Youth with Autism?," Journal of Instructional Psychology 30.2 (2003).

(4) Marjorie H. Charlop-Christy and Susan E. Kelso, "Teaching Children with Autism Conversational Speech Using a Cue Card/written Script Program," Education & Treatment of Children 26.2 (2003).

(5) Jennifer B. Symon, "Parent Education for Autism: Issues in Providing Services at a Distance," Journal of Positive Behavior Interventions 3.3 (2001): 160.

(6) Jennifer B. Symon, "Parent Education for Autism: Issues in Providing Services at a Distance," Journal of Positive Behavior Interventions 3.3 (2001): 160.

(7) Sally J. Rogers, "Empirically Supported Comprehensive Treatments for Young Children with Autism," Journal of Clinical Child Psychology 27.2 (1998): 178.

(8) Jennifer B. Symon, "Parent Education for Autism: Issues in Providing Services at a Distance," Journal of Positive Behavior Interventions 3.3 (2001): 160.

(10) Marjorie H. Charlop-Christy and Susan E. Kelso, "Teaching Children with Autism Conversational Speech Using a Cue Card/written Script Program," Education & Treatment of Children 26.2 (2003).

(11) Jennifer B. Symon, "Parent Education for Autism: Issues in Providing Services at a Distance," Journal of Positive Behavior Interventions 3.3 (2001): 160.

(12) Jennifer B. Symon, "Parent Education for Autism: Issues in Providing Services at a Distance," Journal of Positive Behavior Interventions 3.3 (2001): 160.

(13) Sally J. Rogers, "Empirically Supported Comprehensive Treatments for Young Children with Autism," Journal of Clinical Child Psychology 27.2 (1998): 178.

(14) Alexis Ann Schoen, "What Potential Does the Applied Behavior Analysis Approach Have for the Treatment of Children and Youth with Autism?," Journal of Instructional Psychology 30.2 (2003).

(15) Alexis Ann Schoen, "What Potential Does the Applied Behavior Analysis Approach Have for the Treatment of Children and Youth with Autism?," Journal of Instructional Psychology 30.2 (2003).

Resources for Parents and Families
Links for Parents and Families:
These websites and programs have a variety of useful information and resources about children on the spectrum, especially for parents and families in Westchester County.

The Global and Regional Asperger Syndrome Partnership (G.R.A.S.P): An educational and advocacy organization serving individuals on the autistic spectrum. Their website includes information regarding resources for parents in the New York area.
http://grasp.org

The National Institute of Mental Health Information Booklet, Autism Spectrum Disorders (Pervasive Developmental Disorders): A source of general information on ASD. http://www.nimh.nih.gov/publicat/autism.cfm

The New York Times Health, Autism: A group of recent articles on the subject of autism. http://www.nytimes.com/pages/health/healthspecial2/

Online Asperger Syndrome Information and Support (O.A.S.I.S): Information for parents of children with Asperger Syndrome.
www.udel.edu/bkirby/asperger/

Parent Link: A website for Westchester based resources, links, support groups, parent meetings, conferences and more.
www.westchesterparentlink.org

Treatment and Education of Autistic Children and Children and Related Communication Handicapped Children (TEACCH): Along with promoting the TEACCH approach to treating autism the website offers a large amount of useful information on the subject of autism.
www.teacch.com

Westchester Foundation for Autism and Related Developmental Delays: A Westchester based organization dedicated to improving the quality of life of families having children with autism and related developmental delays.
www.wfautism.org

Programs for Children with Autism in the Westchester Area:

American Camping Association: Internet information on camps for children with Autistic Spectrum Disorder.
www.acacamps.org
(Or call the at (212) 268-7822 for an annual directory)

Connec-to-TalK, LLC: This program is designed to help children on the spectrum enhance social interactions amongst peers in a variety of situations such as: improved peer relationships, successful transitions and generalization of functional language skills.
65 High Ridge Road
Stamford, CT 06902
(203)-530-1014 (203)-252-1369
e-mail: connec-to-talk@hotmail.com

Creative Yogashine: Yoga (group and individual) for children ages 3 and up with emotional, developmental and physical disabilities.
Vitalah Simon, Dance Therapist
Valhalla, New York
(914) 769-8745
www.yogashine.com

Heartsong: Music and art therapy for children of all ages with special needs.
Bronxville and White Plains
(914)-725-9272

Once Upon a River, Innovative Programs for Children: Martial arts, art & music therapy, nutrition counseling and yoga for children 3-16 with conditions such as ADD, anxiety, depression or autism. Children that have issues with anger, mood, self-esteem, behavior or self-control would also benefit. Classes have a 4:1 ratio.
Dr. Jonathon Slater, Director
(914) 591-6868
www.onceuponariver.com

Pegasus: Therapeutic horseback riding for children with special needs
Pleasantville, Bedford Hills, North Salem
(203) 356-9504
www.narha.org

SPARC, Inc.: Special program and resource connection, is a non-for-profit agency providing social, recreation and therapeutic services for youth and adults with developmental disabilities. All age groups serving Westchester some areas of Putnam, Rockland, Dutchess and Orange Counties.
914-243-0583
e-mail: SPARCINC@aol.com
www.sparcinc.org

Special Needs After School Center, Inc.: Provides evaluations, advocacy services and 1:1 certified special education teachers for children first grade through college
Dr. Ratner, Director
199 Main Street Suite 211
White Plains, New York
(914) 761-9518

Common Therapy Treatments and Treatment Approaches:

Applied Behavioral Analysis: Intensive-one-on-one drills instill social and language skills through positive reinforcement.
http://www.behavior.org/autism/

Floortime: A child-directed approach that stresses personal interactions.
www.floortime.org

PECS: Helps build communication skills through use of pictures.
www.pecs.com

RDI: Encourages experience sharing and emphasizes parental involvement.
www.rdiconnect.com

Social Stories: Uses stories to teach social skills and give insight onto other's perspectives.
www.thegraycenter.org

TEACCH: A treatment approach that uses children's individual interests to motivate them to learn in a structured environment.
www.teacch.com

Common Drugs:
Drugs are often used to help with aggression, depression and behavioral problem for children on the spectrum.

Risperidone: Anti-psychotic that has been shown to decrease aggression and hyperactivity

SSRIs: Antidepressants like Prozac may reduce repetitive behaviors.

Anticonvulsants: Drugs like Depakote are being tested for treating aggression

Stimulants: Ritalin may be used to lesson hyperactivity

Leading Practioners:

Tony Attwood, Ph.D. - one of the leading Australian psychologists for Asperger syndrome or high functioning autism. http:www.tonyattwood.com.au/

Jed Baker, Ph.D. - The director of the Social Skills Training Project, a private organization serving individuals with autism and social communication problems.

Stephen Bauer, MD, MPH - A developmental pediatrician and director of the Developmental Unit at The Genesse Hospital in Rochester, NY. He is the author of the widely distributed paper "Asperger Syndrome".

Charles Cartwright, MD - Board certified psychiatrist who has special expertise in the diagnosis and psychopharmacological management of autism spectrum disorders in children, adolescents and adults.

Michelle Dunn, Ph.D. - An associate professor/pediatric neurophysiologist at the Albert Einstein College of Medicine, New York. Dr. Dunn also has developed a social skills curriculum for special needs children that has been implemented in some schools around Westchester (Eastchester Public Schools) and also at her own practice in Mt. Vernon, NY.

Temple Grandin, Ph.D. - She was diagnosed with autism at age 2 and went on to become a gifted animal scientist. She is an assistant professor of animal sciences at Colorado State University and has designed 50% of all the livestock-handling facilities in the U.S.

Carol Gray: An innovative teacher who has been working with children on the spectrum for over 17 years. She is best known for the development of social stories to teach social skills and insight to other's perspectives.

Steven Gutstein, Ph.D. - Designed and trains parents and professionals in RDI- Relationship Development Intervention to address the issues parental involvement and experience sharing.

Herbert D. Hinkle, Esq - An attorney whose area of expertise is Educational Law and is located in Lawrenceville, NJ

Richard Lavoie, MA., M.Ed. - He has served as an administrator of residential programs for children with special needs since 1972 and serves as a consultant on learning disabilities to several agencies. He is best known for his video "How Difficult Can This Be?: The F.A.T. City Workshop".