NERD ALERT!!! This post consists of three papers on Autism…
Paper #1: Overview of Autism Symptoms…
Two Categories of Symptoms
Since the DSM-5 was published, Asperger’s is no longer an official diagnosis (American Psychiatric Association, 2013). It consists of two main categories of symptoms: (1) social deficits and (2) repetitive behaviors and/or limited interests. (American Psychiatric Association, 2013). These social deficits were described in one video as a form of “social dyslexia” (Diamonddave, 2007). A sufferer in another video, described this deficit as an inability to engage in any “theory of mind” conceptualization (Mike Peden, 2009). Keep in mind, the theory of mind concept pertains to an ability to attribute and discern the mental states of others (i.e. emotions, thoughts beliefs. The DSM-5 describes these persistent deficits as involving a range of difficulties in social communication and interaction (American Psychiatric Association, 2013).
The second main classification of symptoms involves repetitive behavior and restricted interests (American Psychiatric Association, 2013). In several assigned videos this week, these restricted interests were described as OCD-like (Diamonddave, 2007; Mike Peden, 2009). One sufferer noted that since this disorder encompasses limitations in social awareness, your mind is instead captured by predictable facts that are readily discerned from the physical world (Diamonddave, 2007). One individual described an avid interest in game shows as a young child due to the predictability of events (Diamonddave, 2007).
Symptoms Causing Parents to Seek Treatment
When reviewing the above list of symptoms, it is clear that underlying all these issues are limitations in the expression of empathy (Mike Peden, 2009). An inability to understand social cues, and emotions in others creates practical limitations in one’s ability to communicate and interact. An inability to grasp the “theory of mind” limits one’s information intake to information readily discernable in the concrete and visual world. As I have come to understand it, these limited interests reflect a desire to compensate for shortcomings, by focusing instead on something that made perfect sense. A great example of this, comes from a recent encounter I had with an elderly lady at work who had dementia. She would spend hours folding the same pile of towels. This activity kept her anxiety at bay, as her mind was able to focus on the task at hand. According to the videos assigned this week, three categories of issues most often capture the attention of concerned adults: (1) OCD-Like behaviors (2) limited communication and (3) restricted interaction (Diamonddave, 2007; Mike Peden, 2009).
The OCD-like behaviors referred to in these videos, reflect limitations in emotional understanding. As a result ASD sufferers display restricted and unusual interests such as, for example, a fascination with vacuum cleaners and their functionality. Repetitive behaviors associated with ASD, also have an OCD-like feel, due to their ability to allay anxiety and prevent temper tantrums.
Teachers and parents in both videos described a range of restrictions in communication (Diamonddave, 2007; Mike Peden, 2009). For example, one mother stated these concerns arouse when her daughter reached 18-months of age, but was unable to find help until she reached three (Mike Peden, 2009). Early intervention is helpful in narrowing the window of delayed development in communication ability for ASD children (Mike Peden, 2009).
I found it interesting that sufferers appeared to complain the most about limitations in social awareness (Diamonddave, 2007; Mike Peden, 2009). Outsiders, on the other hand, described a wider range of symptoms associated with this disorder (Diamonddave, 2007; Mike Peden, 2009). It appeared to me that these limitations in social awareness were conceptualized as a reason for their “differentness” (Diamonddave, 2007; Mike Peden, 2009). It was a key explanation for their struggles and the bullying/teasing they often endured growing up (Diamonddave, 2007; Mike Peden, 2009).
The Importance of Early Diagnosis
According to a video by Mike Peden (2009) ASD sufferer, two classifications of interventions are essential: (1) self-acceptance and understanding (2) self-improvement and skill building. Regarding the issue of self-acceptance and understanding, I was most struck by comments made by Mike Peden (2007), at the end of his video. Coming to a point of understanding what the nature of his disorder was critical in order to deal with it proactively. We see him developing to his utmost potential, rather than restricting himself to the limits of diagnostic expectations. Underlying this progress is an empowered attitude of self-acceptance. As a result, he was able to gain greater understanding of himself and able to address key deficits in communication, and social interaction.
Finally, it is important to note that early intervention is a critical determinant in the progression of this disorder throughout one’s life. Regarding the issue of human development, time is generally of the essence since the brain displays the greatest plasticity in early childhood. For example, Lopata, et al, (2006), states that significant improvements in social skills occurred as a result of their research based interventions. Bauminger, (2007), adds that their research participants displayed significant improvements in emotional knowledge, and socially oriented problem-solving, as a result of their interventions.
Paper #2: A Hypothetical Treatment Program for High-Functioning Autism…
The purpose of this paper is to design a hypothetical treatment program for individuals with high-functioning autism. The DSM-5 manual no longer includes Asperger’s as an official diagnosis (American Psychiatric Association, 2013). Instead, it is now included as a component of Autism Spectrum Disorder (ASD). Symptoms of ASD include social deficits, repetitive behaviors, and limited interests, (American Psychiatric Association, 2013). An interesting video assigned this week, provides unique insight on the inner world of a highly functioning autistic (Mike Peden, 2009). This video describes the social deficits associated with ASD as a form of dyslexia that pertains to an interpretation of social clues (Mike Peden, 2009). With no ability to engage in a “theory of mind” conceptualization, it is impossible to understand the emotions, thoughts or beliefs of others. The ASD sufferer’s world is limited to input that is readily discernible with the five senses. Objective and concrete facts from the physical world are a source information that readily captures the interests of an ASD sufferer. For this reason, I have come to understand ASD an issue of disordered empathy. All symptoms can be attributed to this underlying issue.
Targeted Symptoms & Population
Mike Peden (2009) points out two key areas of intervention that are most essential (1) self-acceptance, and (2) social skill building. This self-acceptance should encompass an awareness of one’s limitations alongside an empowering stance that acknowledges one’s potential (Mike Peden, 2009).. Developing social skills is useful in addressing a predominant complaint of highly functioning autistics in the assigned video (Mike Peden, 2009). Interestingly, suffers in this video pointed out social awareness as a source of differentness and personal struggle. In contrast, loved ones, reported a wider-spectrum of issues as a source of concern. Since all symptoms are a byproduct of limited social awareness and empathy, addressing this issue, is likely to provide the greatest benefit. This limited awareness can involve issues such as a difficulty maintaining friendships, lack of emotional reciprocity, and an inability to understand the rules of social interaction (Lopata, et al, 2006). Finally, in order to define the parameters of this program further, it will be geared toward school-age, highly-functioning autistics.
A cognitive-behavioral orientation will be utilized for the purposes of this hypothetical treatment program. Cognitive-behavioral therapy (CBT) encourages us to adjust our thinking in order to produce changes in mood that will influence our behavioral reactions. (Metcalf, 2011). It combines behaviorism with a cognitive perspective which focuses on our judgments of life events as sources of influence over feelings and behaviors (Metcalf, 2011).
An article I found in the library’s database provides an overview of the only empirically supported social skills CBT approach to autism (Lagueson, et al, 2014). The program reviewed in this article is titled “The Program for the Education and Enrichment of Relational Skills” (Lagueson, et al, 2014). Modifications to the CBT approach for this treatment program include a predictable structure in all sessions with visual supports and explicit verbal feedback (Lagueson, et al, 2014). Additionally, it will be important to give participants repeated opportunities to practice the skills they learn (Lagueson, et al, 2014).
Setting & Mode of Therapy
An ecological systems perspective will also provide guidance for this hypothetical social skills training program. An ecological perspectives views a children’s environment as a causal factor underlying presenting symptoms. The ecological model, describes zones of influence over one’s well-being including: mental, psychological, biological, interpersonal, familial, cultural perspectives (Bauminger, 2007a; Bauminger, 2007b). Adding to this ecological perspective, is insight from systems theory which utilizes a unique systemic, interpersonal viewpoint (Metcalf, 2011). According to this theoretical orientation, the family is considered a system, with a set of governing rules and structure, that provide an interactional homeostasis.
In keeping with these insights, a multimodal treatment design will be utilized. Individualized treatments, described in the “PEERS Treatment Program” (Lagueson, et al, 2014) will be used. These individualized therapy sessions will involve a predictable and structured psychoeducation. Acting as an educator, the therapist’s goal is to foster greater awareness of their behaviors, thoughts, and feelings (Lagueson, et al, 2014). Modeling these skills in a series of role-play demonstrations with other staff is also essential. Concrete steps defining a social task can be provided, with homework for practice elsewhere (Bauminger, et al, 2007b). Working through these skills with an underlying goal of self-understanding will be critical. Incorporating the family’s participation can allow participants an opportunity to practice these assigned skills at home. Finally, where applicable, it will also be useful to provide opportunities to practice these skills at school. Recruiting peer and staff support and participation will be essential.
Lopata, et al, (2006) describes a “Skillstreaming Curriculum” in its research on CBT methods for social skills training with ASD youth. Skills taught in this curriculum include concepts such as basic listening, starting a conversation, complementing, and handling stress (Lopata, et al, 2006). The procedure in the “Skillstreaming Curriculum” include a structured process that involves: (1) defining and modeling skills (2) conducting a role play sessions, (3) providing feedback, and (5) assigning homework (Lopata, et al, 2006). In this respect, it will work well alongside the individualized therapy methods from the PEERS treatment model. Since both treatment models utilize a similar design, participants are provided several opportunities in which to learn and practice the same set of skills.
Multiple Modes of Practice.
As stated earlier, it is important to provide participants several opportunities to practice social skills. For this reason, individual and group therapy will be utilized to provide multiple opportunities to receive social skills training. Finally, providing opportunities for practicing social skills across all elements of a participant’s life can provide reinforcement. For example, in addition to a therapy environment, it would also be useful to allow opportunities for practice in home and at school. Including the participation of family, peers, therapists, and school officials, where possible, can provide an understanding of these skills from multiple perspectives.
The goal of interventions utilized in this hypothetical treatment program includes the development of social understanding and problem solving skills (Bauminger, 2007a; Bauminger, 2007b). Social understanding can be seen in a greater attention to social and emotional cues with a correct interpretative response to this information (Bauminger, 2007a; Bauminger, 2007b). Improvements in social problem-solving skills involve an ability to accurately assess the social task at hand, generate behavioral responses, and examine their consequences (Bauminger, 2007a; Bauminger, 2007b).
Instruction & Feedback.
All interventions will utilize a systematic and predictable structure with repeated opportunities for receiving skills training. Feedback will involve a behavior reward system, in which participants gain and loose privileges based on their ability to follow rules (Lopata, et al, 2006). Naturalistic responses provide a secondary form of feedback through a participant’s life from family members, therapist, peers and school staff.
Examples of Interventions.
Examples of interventions that could be utilized in this hypothetical treatment program can be found from the Skillstreaming Curriculum, (Lopata, et al, 2006), and Peers Program Laguson, et al, (2014). For instance, Lopata, et al, (2006) describe facial expression activities and cooperative games useful in a group therapy setting. An example of a cooperative activity includes participants working together to build objects with the use of one hand (Lopata, et al, 2006). Facial recognition activities involve participants working on correctly identifying the emotions on face pictures (Lopata, et al, 2006). Activities from the Peers Program can provide a cognitive and role-playing interventional component (Lagueson, et al, 2014). For example, Lagueson, et al, (2014) describes a role playing scenario that involves opportunities for learning both positive and negative displays of social behavior. In contrast, cognitive strategies can involve teaching participants how to read social cues, engage in perspective taking exercises, and develop social problem solving skills (Lagueson, et al, 2014). While well-beyond the scope of this paper, I was very impressed with how this program delineates specific skills instructions in a way that is easy to comprehend for ASD sufferers.
What are the expected outcomes of these interventions? A review of research for this paper provides an idea of the long-term outcome for participants. Lopata, et al, (2006) states that participants of the Skillstream Curriculum displayed significant improvements in social skills according to staff and parent report. Lagueson, et al, (2014) also confirms the utility of the Peer program citing improvements in social skills, and increased frequency of peer interaction amongst participants. Finally, research by Bauminger (2007b) indicates the utilization of CBT interventions produced improvements in emotional knowledge, and problem solving ability.
Paper #3: Older Paper Comparing Aspbergers & Autism…
Autism & Aspberger’s
This week’s paper assignment takes a close look at individuals with autism and Aspberger’s. On the one hand, the DSM and ICD-10 both define these two disorders as separate entities. On the other hand, disagreement appears to exist as to whether or not these disorders are separate in nature or ends of a spectrum within a specific disorder. Either way, these diagnoses fall within a classification of “Pervasive Developmental Disorders” (Netherton, et al; 1999, p76). Characterized by symptoms such as communication and language impairment, social and interactive skill disability, and stereotyped behavioral interests: how exactly do these disorders differ (Netherton, et al, 1999, p76)? After all, as per MTV’s True Life segment “I Have Autism” (MTV, 2007) these disorders do appear to present with a highly varied spectrum of symptoms. What follows is a brief description that can help to differentiate between autism and Aspberger’s.
First described by Leo Kanner in the 1940’s, autism was first noted as a disorder of extreme isolation and “aloneness” (Netherton, 1999, p77). Displaying an interactive and social inaccessibility and communicational deficit, these individuals instead displayed greater fascination for abstract objects alongside unusual behavioral deficits.
The huge take-away in watching the assigned video for this week is what seems to be an extreme vacillation between two sets of symptoms (MTV, 2007). It appears these individuals have difficulty sorting through sensory information in an organized way. As a result, while highly sensitive to sensory information, they also appear to be in their own world. Additionally, while these displaying varying degrees of cognitive deficits they are also quite intelligent.
In fact, it appears, they are often aware of the world around them, and have a world of feeling, only unable to express it clearly to others. The world within their minds is different than their external behavioral displays might lead you to believe. With all this said, what is least known about this disorder is its underlying cause. While genetic factors, brain structure abnormalities, chemical imbalances, and viral infections are proposed causes research continues to provide a more definitive explanation (Netherton, et al, 1999).
Based on the textbook’s description and assigned video Aspberger’s appears to be a less-severe form of autism. As stated earlier, while the DSM currently defines it as a separate disorder, there is currently disagreement as to whether it is actually a milder variation along the autistic spectrum (Netherton, et al, 1999; MTV, 2007).
Key differences between Aspberger’s and Autism are readily seen in the levels of functionality displayed. In individuals with Aspberger’s speech onset is rarely delayed, yet more limited than the general population. Additionally, while nonverbal behaviors and social interactions are impaired as compared to the general population, this impairment is generally much less severe. Able to more readily express themselves and interact with the world around them, they display a greater level of functionality and independence. With behavioral symptoms less intrusive, fewer interventions are needed, with an ability to live independently.
So with this overview of the key differences out of the way, what are some key challenges these individuals face daily? What follows is an overview of relevant considerations.
Challenges and Considerations
In an assigned video for this week, we witnessed first-hand some key challenges for those with autism and Aspberger’s. Based on this video, it is clear that individuals suffering from these disorders display a wide range of symptoms that do appear to exist along a continuum. What follows are observations, and considerations to be kept in mind when counseling those with autism.
Jeremy – A Severe Nonverbal Autism
The first story shared in the MTV video titled “I Have Autism”, was of a nonverbal autistic boy named Jeremy. What makes his story unique is the severity of his language impairment. As a nonverbal autistic, his ability to connect with the world around him has been a huge life-long struggle. In fact, the introduction to this video shows him using a “litewriter” device with his mother. When using this device, he can type in his thoughts, and the machine will dictate them back verbally. Prior to the usage of this device, he relays the fact that his world was lonely and frustrating. Unable to express and share his feelings with others, he is saddened by this memory. It is clear, he wants to open up to the world around him, but he is overwhelmed by an array of sensory data, he is incapable of moving beyond.
So what are some key observation’s to note? Firstly, it appears obvious that Jeremy will require lifelong care, and will never be able to live independently. With this in mind, what notable facts regarding Jeremy’s needs and challenges can help those providing his care? Providing an environment that can allow him to remain engaged with the world around him is key. This can empower him to meaningfully relate to others and cement friendships with those around him. Also important in his case, are coping skills to help him handle the occasional stressful sensory overloads. All this, of course, will need to occur within an environment in which he can be assisted in safely engaging in his ADL’s as independently as possible.
Jonathan – Autism with A Savant Component.
The second case study of Autism in the MTV video titled “I Have Autism” is that of Jonathan. In contrast to Jeremy, Jonathan appears to display a less severe communicative and speech impairment. Instead, in Jonathan’s case, his impairments appear to involve a difficulty understanding abstract thoughts, and limited conversational ability. Finally, with an increased tendency toward emotional labiality, he is prone to occasional outbursts. This appears to occur whenever he is overwhelmed from a sensory and/or emotional standpoint.
Key challenges in Jonathan’s case, in addition with assistance with basic ADL’s include management of occasional sensory/emotional overloads. What is clear in Jonathan’s case is his desire to manage the occasional outbursts that come with this. Techniques such as the usage of headphones to lessen sensory input, and assistance in managing emotions are key. Finally, holding a unique artistic savant, our textbook mentions this special skill can “become a useful treatment tool as a conduit toward normalization.” (Netherton, et al, 1999, p89).
Elijah – Asperber’s Disorder
Most readily described as a less severe form of autism, Elijah appears to be the most highly functioning of all individuals in this video. With some speech delays, and motor dis-coordination, he also appears to be somewhat impaired in the context of social interactions. What is notable in Elijan’s case, is how the lesser degree of severity, changes the nature of the interventional considerations. Not needing assistance any meaningful assistance with ADL’s, Elijah can easily live independently as an adult.
So what considerations should be taken in Elijah’s case? Our textbook mentions education and vocational training with a goal towards independent living arrangements (Netherton, 1999, p94). Additional considerations to address in cases such this can be seen in reviewing Elijah’s struggles more closely. In particular, it seems he fears sharing his diagnosis of autism with others, for fear of stigmatization and negative judgments from others. He is somehow aware of his disorder, and how it differentiates him from others. Learning how to accept and handle this key issue. Doing so will be a critical factor in his degree of adeptness in traversing the world around him. Assistance in handling the emotions surrounding this issue, with additional social skill education, can make a world of difference