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Abstract
In 2013, the fifth edition of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) grouped all subcategories of autism-related disorders in one umbrella, and it is called autism spectrum disorder or ASD. Characterized by repetitive behaviors and communication and social skills deficits, many children from all around the world are afflicted with this disorder. Throughout the years since its discovery, researchers and mental health experts have been interested in completely understanding the nature, etiology, and possible treatments for ASD. Through continuous research efforts and studies, several perspectives have been established to explain the causes of autism. These perspectives include the theory of mind hypothesis of autism, insights from interactionist perspective, and several hypotheses from different behavioral theorist. Although there are early warning signs from infancy, it is said that diagnosis is more reliable when a child reaches the age of three onwards. Indeed, it is possible for a child with ASD to live a better life through early diagnosis and application of proper treatment approach.
Autism Spectrum Disorder: An Overview
According to the Centers for Diseases Control and Prevention or CDC (2016), 1 to 2 percent of the populations of Asia, Europe, and North America have autism spectrum disorder or ASD. In the United States alone, it has been estimated that 1 in every 68 children has been diagnosed with this condition (CDC, 2014). Simply known as “autism” for many people, ASD is a serious condition that has been receiving attention for many years. The National Institute of Mental Health (2016) defines this condition as “the name for a group of developmental disorders,” which includes a spectrum of “symptoms, skills, and levels of disability.” Although the symptoms vary from person to person, children who have this disorder often have difficulties in establishing connection with their peers and they exhibit behaviors that are abnormally repetitive. Sometimes, the symptoms are mild but there are also severe cases. Although the word autism was first used in 1908 to describe self-absorbed schizophrenic patients, it was not until 1943 when a published paper was released describing children who displayed a strong desire to be alone and be engaged in repetitive behaviors (Sole-Smith, 2014). This observation was made by Dr. Leo Kanner, a child psychiatrist. A year later, a Viennese pediatrician named Hans Asperger reported the cases of children with mild symptoms of autism, and it was called as the Asperger’s Syndrome (Wolff, 2004). Autism continued to become a topic of interest for many mental health experts. In 1980, the Diagnostic and Statistical Manual of Mental Health Disorders (DSM) included “infantile autism” on its list before changing the term to “autism disorder” in 1987 (Sole-Smith, 2014). In the fifth edition of DSM, the condition was termed autism spectrum disorder, which involves two categories for social communication impairment and development of repetitive behaviors (Sole-Smith, 2014). Truly, from the time that it was discovered many decades ago, a number of researchers and clinicians have extended efforts to understand the conditions of those who have ASD in order to help them with their struggles. In line with these efforts, several journals were also established: The Journal of Autism and Developmental Disorders, which started in 1971, The Journal of Autism and Childhood Schizophrenia, the Autism: The International Journal of Research and Practice, the Focus on Autism and Other Developmental Disabilities, which started in 1985, and The International Autism Research Review that started in 1987. Many other journals followed, and all of these aim to provide more information about ASD both from research and practice. The following information about the symptoms, causes, diagnosis, treatments, and cases are all based on studies about ASD.
Symptoms
The symptoms of ASD in children may manifest as early as the first two years of life. Based on several retrospective and prospective studies, early warning signs for ASD in infants (0-12 months) and toddlers (12-24 months) include unusual patterns of vocal sounds, less gestures, lack of interest in objects or the idea of sharing it to others, lack of response to others, atypical affect, less interest in social interactions, lack of smile, less attention to people’s faces, often engaged in repetitive play, passive, irritable, distressed, and atypical eye gaze (Boyd, Odom, Humphreys, & Sam, 2010). These early symptoms are said to be useful for early diagnosis and intervention. Although most of the symptoms are behavioral, there are researchers who claim that early physiological signs can also detect possible ASD later in life. For instance, according to Courchesne, Carper, and Akshoomof, children who were diagnosed with ASD “had a head circumference that was not enlarged at birth, but a rapid acceleration occurred during the first 2 years of life” (as cited in Boyd, Odom, Humphreys, & Sam, 2010). In other words, head circumference at birth may also serve as an ASD predictor.
For pre-school children ages 3 to 5, there are also common ASD symptoms. In terms of spoken language, their speech development are often delayed and the tone of their voice tend to be monotonous (National Health Service, 2016). Moreover, they tend to repeat some phrases or words and although they can construct sentences, they often communicate with others using single words (National Health Service, 2016). The way they respond to people are clearly not normal. For example, they do not respond when their names are called and they also resist cuddles from parents unless they are the ones who initiate it (National Health Service, 2016). School-age children with ASD also have distinct behaviors. First, they tend to do repetitive actions (e.g., rocking back and forth) and play repetitively without using their imagination (National Health Service, 2016). They are also resistant to change. When their routine has change, they get upset. In addition, many of them have unusual sensory interest (e.g., sniffing objects and people) (National Health Service, 2016).
Many of the symptoms of ASD in pre-school children are also carried as they grow a bit older although new symptoms also develop overtime. For school-age children (more than 5 years of age), they usually talk “at” people instead of having a normal two-way communication (National Health Service, 2016). Furthermore, they take words literally, which means that they cannot comprehend figures of speech or sarcastic remarks. They are also anti-social, having only few friends and lack of knowledge about other people’s personal space. In addition, they have no concept of facial expressions and gestures (National Health Service, 2016). Just like when they were younger, they continue to make repetitive actions and they also continue to have unusual sensory interest. Lastly, they tend to develop a strong interest in a specific subject or hobby (National Health Service, 2016). Children with ASD usually carry these symptoms with them until adulthood unless they are given appropriate interventions.
Causes Based on Theoretical Perspectives
The Theory of Mind Hypothesis of Autism
One of the psychological theories which help explain the causes of the symptoms of ASD is called the theory of mind hypothesis. The term “theory of the mind” “refers to the ability to attribute mental states, such as desire, knowledge, and belief, to oneself and other people as a means of explaining behavior’ (Tager-Flusberg, 1999). For normal children, their ability to understand other people’s emotions and mental states usually starts at the age of three onwards. However, this is not true for children with ASD. Cognitive psychologists believe that these children actually have cognitive deficits. Known as the theory of mind hypothesis of autism, the concept explains that many of the symptoms of children with ASD are due to cognitive deficits which affect their ability to understand other people (Tager-Flusberg, 1999). Specifically, cognitive deficits of children with ASD make them see social interactions as a complex process. Because routines and familiarity help reduce this complexity, autistic children resist changes in routine. Also, they tend to be more responsive with their families because they are familiar with them, while on the other hand, they do not often respond to strangers. The theory of the mind also helps explain the communication-related symptoms of ASD. Due to cognitive deficits, children with ASD do not have the ability to see language as a tool to communicate with others (Tager-Flusberg, 1999). Overall, the theory of the mind hypothesis of autism focuses on the social and language abnormality of children with ASD as possibly caused by cognitive deficits.
Behavioral Theories of Autism
Theories based on social-environmental causes. Several theorists believe that autistic behaviors are caused by social-environmental factors. One of these was Charles Ferster, a behavioral psychologist. Ferster believe that the reinforcements that children with ASD receive in their homes are related to the further development of autistic behaviors. Although he points out that normal children and those who have ASD have similar behaviors, there are differences in terms of the frequency of these behaviors. According to Ferster, “the tendency for parents of children with autism to reinforce inappropriate behavior that functions to escape from an aversive stimulus, results in a decrease of social control and an increase in tantrums and self-destructive behaviors” (Hixson, Wilson, Doty, & Vladescu, 2008). Despite Ferster’s emphasis on the role of parenting in the development of autistic behaviors, he does not point to them as the sole cause or the main reason behind the condition. On the other hand, Philip Drash and Roger Tudor proposed a theory which describes autism to be a “contingency shaped disorder of verbal behavior” (Hixson, Wilson, Doty, & Vladescu, 2008). In a nutshell, this theory suggests that a spoken language deficiency highly contributes to autism, which means that without such deficiency, autism will not occur. There are four premises behind this theory. First, reinforcements play a significant role in the development or lack of development of spoken language (Hixson, Wilson, Doty, & Vladescu, 2008). For instance, the more parents reinforce the use of voice for communication, the less it is likely for children to have delayed speech development. Second, parents or caregivers may unintentionally reinforce children’s behaviors that are disruptive. Third, “disruptive and task-avoidance responses are a primary characteristic of children with autism” (Hixson, Wilson, Doty, & Vladescu, 2008). Lastly, if the normal verbal behavior of a child is incompatible with the disruptive behaviors, the verbal behavior will not develop appropriately. All in all, this theory focuses on the role that the children’s environmental condition plays in relation to the development of autistic behaviors.
Theory based on interactionist perspective. From an interactionist perspective, autism is considered to be a result of the interaction of genetic and other factors, which include environmental conditions. Based on one of the tenets of behavior analytic theory or autism which was proposed by Lovaas and Smith in 1989, a mismatch between children’s nervous system and the environment leads to autism (Hixson, Wilson, Doty, & Vladescu, 2008). Aside from this, the theory have other tenets which touch on the possible improvement of autistic behaviors when learning principles are used to address behavioral and language deficits.
Screening and Diagnosis
Although there are early warning signs in ASD, diagnosis at the age of 14 months and below are not very reliable. It is said that at this age, there is less stability of symptoms (Landa, 2008). On the other hand, pediatricians in the United States normally conducts ASD screening at age 18 months, and this screening is repeated at the age of 24 months. Several types of checklists are used for the screening, such as the Developmental Behavioral Checklist-Parent, the Modified Children’s Autism Test, the Autism Behavior Checklist or the Autism Screening Questionnaire (Brentani, et al., 2013). Despite early screening, several studies suggest that diagnosis for ASD are more stable at the age of three or beyond. The diagnostic criteria for ASD are based on two domains: impairment in social communication skills (e.g., lack of facial expression, lack of interest towards others, and developmental delay in language acquisition) and the presence of behaviors and interests that are repetitive and restrictive (Brentani, et al., 2013). For mental health experts to determine whether a child has ASD, several items must be present. Specifically, a child must exhibit 6 or more items from the two domains (Brentani, et al., 2013). When a child is suspected to have ASD, mental health experts use different assessment tools for proper diagnosis. Two of the most commonly used tools are Autism Diagnostic Observation Schedule (ADOS) and Autism Diagnostic Interview Revised (ADI-R). With early and proper diagnosis, children with ASD may be given recommendations for appropriate interventions.
Treatments
Different treatments or interventions are given to children with ASD depending on the age and the severity of their symptoms.
Non-pharmacological Approach
Parent training. Because parents play a significant role in the lives of their children, parent training are also recommended to those who have autistic children. This intervention works under the assumption that “child behavior is learned and maintained through contingencies within the family context and that parents can be taught to change these contingencies in order to promote and reinforce appropriate behavior” (Brentani, et al., 2013). This type of intervention works best with parents who are highly motivated and eager to improve the lives of their children.
Applied behavioral analysis. Applied behavioral analysis or ABA is often used in schools and clinics. The main goal of using applied behavioral analysis or ABA is to encourage positive behaviors and discourage the negative ones in order to improve children’s skills (CDC, 2015). Throughout an ABA program, the behavioral progress of children are observed and measured. Different types of ABA are available, such as discrete trial training (DTT), early intensive behavioral intervention (EIBI), pivotal response training (PRT), and verbal behavior intervention (VBI) (CDC, 2015). ABA can also be combined with other types of interventions if needed.
Cognitive behavioral treatment. Cognitive behavioral treatment targets the improvement of thought patterns of children with ASD. Several studies prove the efficacy of this approach. According to Brentani et al. (2013), “improvements in anxiety, self-help, and daily living skills have been reported, with 78% of 7-11 year-olds in the CBT-treated group rated as positive responders in one trial.” This is often given to school-age children and those who are older.
Pharmacological Approach
Pharmacological treatments are used not to treat or eliminate ASD but to minimize or manage the symptoms that are associated with it. For instance, around 50% of children with ASD have aggressive behaviors, and according to Nazeer, antipsychotics can help control aggressiveness that are associated with autism (as cited in Brentani, et al., 2013). Just recently, another drug was approved by the U.S. Food and Drug Administration for autistic children. It is the aripiprazole which is used to manage irritability for children ages 6 to 17 (Brentani, et al., 2013). These are just two among the many drugs that are used to help children with ASD so that they can live in the most normal life possible.
Chris: A Child with ASD
Chris is a school-age boy and an only child from a two-parent family. As a child with ASD, he has low verbal reasoning skills, attention deficit, has history of oppositional behavior, and is often aggressive (Ames & Weiss, 2013). He is particularly interested with video games and when he feel anxious and stressed, he tends to act like the characters from the games. Aside from this, he has trouble establishing connection with others and understanding their emotions. As an intervention, Christ was grouped with four other autistic children, who also has significant anxiety issues, for a 12-week CBT program (Ames & Weiss, 2013). A lead therapist headed the group while each child was also paired with doctoral students in clinical psychology who served as co-therapist. Each session lasted for 90 minutes (Ames & Weiss, 2013). At the same time, the program also included the participation of parents in a psycho-educational classes aimed to educate them about anxiety and develop their skills to help their child (Ames & Weiss, 2013). Like the other children, some modifications were done in the program to suit Chris’ needs. As a result, Chris was able to maintain his attention in the one-on-one session. He also started to identify different emotions. He was also motivated by the activities and games that were part of the program. It was also reported that “Chris was successful in improving his overall functioning within the group setting, despite his initial aggressive behavior” (Ames & Weiss, 2013). Overall, significant improvements were observed with Chris’ behavior after the completion of CBT program.
Conclusion
Many children are suffering from autism spectrum disorder. With the right knowledge about its nature, symptoms, and causes, one may be able to understand that these children need attention and intervention. Although it may not be totally prevented, ASD is treatable. Early screening and diagnosis are certainly important to do this. Like Chris, children with ASD can still improve their behavior and their overall human functioning through the means of different intervention strategies. Most importantly, the success of any treatment heavily relies on the parents’ dedication and willingness to support their children in every step of the way.
References
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Brentani, H., Silvestre de Paula, C., Bordini, D., Rolim, D., Sato, F., Portolese, J. , Pacifico, M., & McCracken, J. (2013). Autism spectrum disorders: An overview on diagnosis and treatment. Revista Brasileira de Psiquiatria, 35, S62-S72. doi:10.1590/1516-4446-2013-S104
CDC (2014). CDC estimates 1 in 68 children has been identified with autism spectrum disorder. Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/media/releases/2014/p0327-autism-spectrum-disorder.html
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