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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Autism Spectrum Disorders from Theory to Practice Apply the latest ASD theory to assessment and intervention in real-world clinical environments In Autism Spectrum Disorders from Theory to Practice, a team of experienced interventionists deliver a practical application of modern theory regarding autism spectrum disorders (ASDs) to common, real-world clinical situations. Hands-on guidance is paired with advice on culturally appropriate and responsive practices informed by professionals who collectively have over 40 years of combined speech pathology experience. The work of special contributors like Dr. Pamela Wiley, who is the Founder and President of the Los Angeles Speech and Language Therapy Center, appears alongside evidence-based ASD intervention instruction that draws from the latest studies and from the authors' assessments and interventions with clients from a diverse range of backgrounds. When combined with the reader's own professional competence, clinical experiences, and continuing education, this book is a powerful resource that will improve patient outcomes. Autism Spectrum Disorders readers will also find: * Personal anecdotes from the authors' clinical practices to help illustrate the application of the concepts discussed within * Active Learning Tasks that educators can use to promote learning activities that encourage direct engagement with the material * Helpful and illustrative diagrams included throughout the text to help elucidate points and clarify information in each chapter * Goal Spotlights that provide sample intervention goals practitioners can use with actual clients with autism * Reflection Letters in which individuals from various perspectives and backgrounds--from autism researchers to developmental psychologists, advocates such as Holly Robinson Peete, and adults thriving with autism--describe their experiences Autism Spectrum Disorders from Theory to Practice is a useful reference for new and experienced practitioners in the field of autism research, speech-language pathologists, developmental psychologists, adapted physical education teachers, professors, and those affected by ASD in their everyday life.
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Table of Contents
Cover
Title Page
Copyright Page
About the Authors
Introduction
CHAPTER 1: Historical Perspectives of Autism Spectrum Disorder
CLINICAL CONSIDERATION
A NEURODEVELOPMENTAL DISORDER: AUTISM AND THE BRAIN
THE CLINICAL TEAM: WHO AND WHAT
NEURODIVERSITY
SUMMARY
TEST QUESTIONS
REFERENCES
FURTHER READINGS
CHAPTER 2: Indications for Assessment
AUTISM AND ASSESSMENT OF CULTURALLY, LINGUISTICALLY DIVERSE POPULATIONS
ASSESSMENT TOOLS
INFORMAL ASSESSMENT
THE GENDER DISPARITY
COMORBIDITY
CLINICAL APPLICATION
GOAL SETTING
SUMMARY
TEST QUESTIONS
REFERENCES
FURTHER READINGS
CHAPTER 3: Identifying Social Communication Challenges
A NOTE ON CULTURAL VARIATION
NONVERBAL SOCIAL COMMUNICATION CHALLENGES
CLINICAL APPLICATION
CLINICAL APPLICATION
VERBAL SOCIAL COMMUNICATION CHALLENGES
EXECUTIVE FUNCTION
SOCIAL RECIPROCITY AND RAPPORT
OBTAINING FIRSTHAND REPORTS
CLINICAL RELEVANCE
SUMMARY
TEST QUESTIONS
REFERENCES
FURTHER READINGS
CHAPTER 4: Early Intervention and Autism
UNDERSTANDING NEUROTYPICAL DEVELOPMENT
CONSIDERING NEUROTYPICAL DEVELOPMENT
FAMILY INVOLVEMENT
EVIDENCE‐BASED APPROACHES
IMPORTANCE OF CONNECTION
IMPORTANCE OF PLAYFULNESS
ORGANIZATION IN THERAPY
ENVIRONMENTAL ARRANGEMENT
THE IMPORTANCE OF INTERPROFESSIONAL COLLABORATION
SUMMARY
TEST QUESTIONS
REFERENCES
FURTHER READINGS
CHAPTER 5: School‐Age Children Part One
TRANSITION TO SCHOOL
DETERMINING AN APPROPRIATE EDUCATION SETTING
GOAL SETTING
BEHAVIORAL SUPPORTS FOR CHILDREN WITH AUTISM IN THE CLASSROOM
COMMON SCHOOL DAY CHALLENGES
SUMMARY
TEST QUESTIONS
REFERENCES
CHAPTER 6: School‐Aged Children Part Two: The Later Years
PARENTS AND THE ADOLESCENT REVOLUTION
SETTING THE TONE FOR SUCCESS
ADOLESCENCE AND PRAGMATIC CONSIDERATIONS
TOP ADOLESCENT SOCIAL SKILLS CONCERNS AND SOLUTIONS
DEVELOPING SOCIAL TARGETS
ADOLESCENT GIRLS AND MENSTRUATION
SUMMARY
TEST QUESTIONS
REFERENCES
FURTHER READINGS
CHAPTER 7: Autism and Adulthood
INTRODUCTION
AUTISM, ADULTS, AND CURRENT KNOWLEDGE
MY JOURNEY WITH AUTISM
THE PROCESS OF STRENGTHENING: PARENT PERSPECTIVES
ADULTS AND CULTURAL CONSIDERATIONS
AUTISM IS A LABEL: IT DOES NOT DEFINE YOUR POTENTIAL
THE IMPORTANCE OF ENVIRONMENT
CORE TREATMENT AREAS
SUMMARY
TEST QUESTIONS
REFERENCES
FURTHER READINGS
CHAPTER 8: Autism and Echolalia
ECHOLALIA 101
STAGES OF GESTALT LANGUAGE ACQUISITION
TYPES OF ECHOLALIA
CONSIDERING FUNCTIONALITY
THERAPEUTIC ACTION PLAN
SUMMARY
TEST QUESTIONS
REFERENCES
FURTHER READINGS
CHAPTER 9: Autism and Social Justice
CULTURAL COMPETENCE AND AUTISM SPECTRUM DISORDER
THE INTERSECTION OF SOCIAL JUSTICE AND AUTISM
ACCESS TO SERVICES AS A SOCIAL JUSTICE ISSUE
HARD TRUTHS: CASES TO EXPLORE
SUMMARY
TEST QUESTIONS
REFERENCES
FURTHER READINGS
CHAPTER 10: Autism and Augmentative and Alternative Communication
NONVERBAL AND MINIMALLY VERBAL CLIENTS WITH AUTISM
TYPES OF AUGMENTATIVE AND ALTERNATIVE COMMUNICATION
INTERVENTION SUGGESTIONS
INTRODUCING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION
INTERVENTION CONSIDERATIONS
SUMMARY
TEST QUESTIONS
REFERENCES
FURTHER READINGS
CHAPTER 11: Scope of Practice Considerations and Service Delivery Models
COMMUNICATION CONSIDERATION
SERVICE DELIVERY MODELS
SEVEN STEPS FOR SUCCESSFUL COLLABORATION IN THE SCHOOL SETTING
TEST QUESTIONS
REFERENCES
FURTHER READINGS
CHAPTER 12: Autism and the Parent
THE ROLE OF DISPARITY
THE ROLE OF MENTAL HEALTH
CULTURAL CONSIDERATIONS
CREATING OPPORTUNITIES TO PROVIDE KNOWLEDGE
ENGAGING PARENTS IN THE GROUP SETTING
CAREGIVER CENTERED EVIDENCE‐BASED APPROACHES
SHIFTING PARENT PERSPECTIVES: CREATING A WINNING MENTALITY
SUMMARY
TEST QUESTIONS
REFERENCES
FURTHER READINGS
Glossary
Answers to Test Questions
Index
End User License Agreement
List of Tables
Chapter 1
TABLE 1.1 DSM IV categories used in the formal diagnosis of ASD
Chapter 2
TABLE 2.1 Autism‐specific tests.
TABLE 2.2 Core areas tests.
TABLE 2.3 Informal evaluations.
Chapter 3
TABLE 3.1 Social milestones summarized by the American Speech–Language–Heari...
TABLE 3.2 Examples of social skills differences across cultures.
TABLE 3.3 A sentence can have different meanings with different tone and str...
TABLE 3.4 Positive and negative statements.
TABLE 3.5 Ways to shift to clinical writing.
TABLE 3.6 Examples of clinical language.
Chapter 4
TABLE 4.1 Early language developmental milestones and therapeutic activities...
Chapter 5
TABLE 5.1 Common terms used in the individual education plan.
TABLE 5.2 Sample lesson plan.
TABLE 5.3 Steps to prepare for successful transitions.
Chapter 6
TABLE 6.1 Top parental concerns for their adolescent or adult with autism.
TABLE 6.2 Therapeutic Mediums. Defined.
TABLE 6.3 Video modeling.
TABLE 6.4 Common adolescent skills concerns.
Chapter 7
TABLE 7.1 Key components for success of the PS+ASD supports.
TABLE 7.2 Primary occupational categories, RIASEC test.
Chapter 8
TABLE 8.1 The stages of gestalt language acquisition.
TABLE 8.2 Severity of echolalia.
TABLE 8.3 Treatment of echolalia in people with autism spectrum disorder....
Chapter 9
TABLE 9.1 Key Definitions according to the American Speech‐Language Hearing ...
Chapter 10
TABLE 10.1 Examples of clinician intervention activities adapted for AAC use...
List of Illustrations
Chapter 1
FIGURE 1.1 One domain for autism spectrum disorders.
FIGURE 1.2 Changes in the diagnosis of autism in successive editions of the ...
FIGURE 1.3 Autism Spectrum Disorders.
FIGURE 1.4 Medical and social models of autism.
Chapter 2
FIGURE 2.1 Examples of points of concern reported by parents.
FIGURE 2.2 Recall the two key diagnostic criteria for ASD reviewed in Chapte...
FIGURE 2.3 Evaluation process for ASD assessment.
FIGURE 2.4 Note the gender disparity in ASD with more prevalence among boys ...
Chapter 3
FIGURE 3.1 Social skills challenges.
Chapter 4
FIGURE 4.1 Clinical manifestations.
FIGURE 4.2 Providing parents with examples of how the child's behaviors rela...
FIGURE 4.3 The autism focused intervention resources and modules.
FIGURE 4.4 Establishing a natural connection. Interventionist and client sha...
FIGURE 4.5 Levels of play flow chart.
FIGURE 4.6 Play items for the interventionist's “tool box.”
Chapter 5
FIGURE 5.1 Transition from home to school: from individualized family servic...
FIGURE 5.2 Most to least restrictive educational environments.
FIGURE 5.3 Cube chairs.
FIGURE 5.4 Different options that can facilitate success for students with a...
FIGURE 5.5 Visual cue card.
FIGURE 5.6 Visual behavior reminders: “Sit down,” “Quiet”, “Quiet hands,” an...
FIGURE 5.7 Examples of physical behavioral expectations charts.
FIGURE 5.8 Token economy system.
FIGURE 5.9 Delayed reinforcement system.
FIGURE 5.10 Use of a conversation train to prompt conversation maintenance....
FIGURE 5.11 Checklist to support student executive functioning to aid with o...
Chapter 6
FIGURE 6.1 Components to successful adolescent therapy session implementatio...
FIGURE 6.2 Active learning strategies.
FIGURE 6.3 The formula to follow when leading social skills in a group setti...
FIGURE 6.4 Teaching the task and providing prompting.
FIGURE 6.5 Basic behavioral principles.
Chapter 7
FIGURE 7.1 Dr. Pamela Wiley with her amazing interventionists and staff.
FIGURE 7.2 Outcomes from the 2017 National Autism Indicators report.
FIGURE 7.3 Areas of difference and challenges for an adult with autism.
FIGURE 7.4 Three key areas of social challenge.
FIGURE 7.5 Current events discussed: (left to right) George Floyd, homelessn...
FIGURE 7.6 Employment Readiness Training Labratories, Los Angeles Speech and...
Chapter 8
FIGURE 8.1 Differences in pronominal substitutions in mitigated echolalia.
FIGURE 8.2 Fading cues.
Chapter 9
FIGURE 9.1 The cultural competence continuum.
FIGURE 9.2 Equity, not equality.
FIGURE 9.3 The cultural competence continuum.
FIGURE 9.4 Disparities that impact a minority family of a child with autism....
Chapter 10
FIGURE 10.1 An example of a speech‐generating application.
FIGURE 10.2 A simple option board incorporating core vocabulary.
FIGURE 10.3 The different types of communicative competence.
FIGURE 10.4 Example modeling intervention.
FIGURE 10.5 Using communication devices in small group intervention settings...
FIGURE 10.6 Working from least to most prompts.
FIGURE 10.7 Using communication devices in the classroom setting.
FIGURE 10.8 Ensure that the communication device is readily accessible at al...
FIGURE 10.9 Dr. Belinda reading a book using a standard book board and the s...
Chapter 11
FIGURE 11.1 Interprofessional education compared with interprofessional prac...
FIGURE 11.2 TAP: temperament, aptitude and patience.
FIGURE 11.3 The interventionist works with a group of four children with aut...
FIGURE 11.4 In Home Therapy Considerations.
FIGURE 11.5 Example of a teletherapy session with a teen client with ASD usi...
Chapter 12
FIGURE 12.1 Developing a parent's confidence.
Guide
Cover Page
Title Page
Copyright Page
About the Authors
Introduction
Table of Contents
Begin Reading
Glossary
Answers to Test Questions
Index
Wiley End User License Agreement
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Autism Spectrum Disorders from Theory to Practice
Assessment and Intervention Tools Across the Lifespan
Belinda Daughrity, Ph.D., CCC‐SLP
Assistant Professor, California State University
Long Beach, CA, USA
and
Ashley Wiley Johnson, Ph.D., CCC‐SLP
Vice President, LA Speech and Language Therapy Center
Los Angeles, CA, USA
This edition first published 2023© 2023 John Wiley & Sons Ltd
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Belinda Daughrity and Ashley Wiley Johnson to be identified as the authors of the editorial material in this work has been asserted in accordance with law.
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Limit of Liability/Disclaimer of WarrantyThe contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.
Library of Congress Cataloging‐in‐Publication DataNames: Daughrity, Belinda, 1984– author. | Johnson, Ashley Wiley, 1985– author.Title: Autism spectrum disorders from theory to practice : assessment and intervention tools across the lifespan / Belinda Daughrity and Ashley Wiley Johnson.Description: First edition. | Hoboken, NJ : Wiley‐Blackwell, 2023. | Includes bibliographical references and index.Identifiers: LCCN 2022019638 (print) | LCCN 2022019639 (ebook) | ISBN 9781119819561 (paperback) | ISBN 9781119819578 (adobe pdf) | ISBN 9781119819585 (epub)Subjects: MESH: Autism Spectrum DisorderClassification: LCC RC553.A88 (print) | LCC RC553.A88 (ebook) | NLM WS 350.8.P4 | DDC 616.85/882–dc23/eng/20220613LC record available at https://lccn.loc.gov/2022019638LC ebook record available at https://lccn.loc.gov/2022019639
Cover image: © Tony Anderson/Getty Images; © Klaus Vedfelt/Getty ImagesCover design by Wiley
About the Authors
Dr. Belinda Daughrity is a California state‐licensed and American Speech–Language–Hearing Association (ASHA) certified bilingual speech–language pathologist (SLP) with more than 20 years of experience working with individuals with autism. She earned her BA in English and Spanish from Spelman College. She earned her MA in speech–language pathology and audiology from New York University before earning her doctorate at University of California, Los Angeles (UCLA), where she worked in the world‐renowned Center for Autism Research and Treatment. During her training at UCLA, she worked on cutting edge research for autism intervention and furthered her expertise in evaluation procedures via clinical and research training in the Autism Diagnostic Interview – Revised and the Autism Diagnostic Observation Schedule, second edition, often considered the “gold standard” of autism assessment.
Belinda has presented at national and international conferences about autism spectrum disorder (ASD) including: the ASHA, the National Black Association of Speech–Language and Hearing, the California Speech–Language–Hearing Association, the Illinois Speech–Language and Hearing Association, the ASHA Connect Conference, and the International Society of Autism Research Regional International Meeting for Autism Research. She has teaching experience at New York University, UCLA, and Chapman University. Currently, she serves as an assistant professor at California State University, Long Beach in the speech–language pathology department.
Her clinical experience includes assessment, individual and group intervention, and social skills in the home, private practice, schools, and telepractice settings. She has led social skills groups for children with autism in preschool, elementary, middle, and high school. Bilingual in Spanish, she has worked with families from culturally and linguistically diverse backgrounds to promote caregiver training and education. Additionally, Belinda serves as a clinical supervisor to train speech–language pathologists and SLP assistants. She hopes that this textbook helps current and future clinicians working with children with autism and their families.
Dr. Ashley Wiley Johnson is Vice President of Los Angeles Speech and Language Therapy Center, a family‐owned small business founded over 41 years ago, which is at the forefront of working with people with autism and other special needs across the lifespan. A second‐generation speech pathologist, Ashley manages licensed speech pathologists, therapists, and behaviorists serving clients in early intervention programs, social skills classes, summer programs, employment readiness programs, and typical and therapeutic preschool programs across five sites within Los Angeles County. As part of her practice, she consults with school districts and charter schools to help improve their delivery of speech and language‐based services to students with special needs. She has focused on the over‐identification of African‐American and Latino students classified for special education services, has created innovative pathways to service delivery for people with autism across the lifespan, forged partnerships between public school systems and private practice setting, and brought traditional speech therapy methods into the classroom setting to encourage facilitation and increased development in students with speech and language delays.
Ashley began her professional career in the public school system serving as a bilingual SLP and ultimately as the lead preschool district‐wide assessor. During her tenure, she developed a passion for working to decrease and build awareness of disparity in provision of services for Black and Hispanic students with autism. Using her fine arts background, Ashley developed Drama Kings and Queens (DKQ), a six‐ to eight‐week summer program and weekly social skills class focused on developing pragmatics and creativity for students ages 5–15 years with autism through the arts.
Ashley is a proud graduate of the University of North Carolina at Chapel Hill. She obtained her Masters of Arts from San Josè State University in Communication Sciences and Disorders and her PhD from Claremont Graduate School in Educational Studies with an emphasis on urban education and special education.
As a bilingual SLP, Ashley is a sought‐after national trainer, lecturer and presenter addressing a range of topics around service delivery innovation, effective social skills treatment models, and arts advocacy for children with autism and their families. Ashley also is active in leadership in the ASHA, where she most recently held the title of Topic Chair for the 2021 ASHA Convention. She currently sits on the board of directors of Child 360, a statewide organization at the forefront of providing access to quality early childhood education for children across California.
Ashley is married to Alex Martin Johnson Esq., and they are the proud parents of a precocious and adorable daughter, Alexa Danielle and son, Alain.
Introduction
This textbook is the product of two interventionists with more than 40 years of combined experience working with individuals with autism and their families. In each chapter, we share personal anecdotes from our own clinical practices to help illustrate the application of theoretical approaches. It is our intent, that this book will be used as a bridge to support an interventionist's ability to think of the theories surrounding autism and then put them into actual practice.
Additionally, several chapters end with a reflection letter from individuals from various perspectives and backgrounds: autism researchers, speech–language pathologists, developmental psychologists, adapted physical education teachers, professors, celebrity advocates like Holly Robinson Peete, and, most importantly, adults living and thriving with autism each day of their lives.
Further, we are delighted to have a special contributor to write Chapter 7: Autism Spectrum Disorder in Adulthood. Dr. Pamela Wiley, founder and president of Los Angeles Speech and Language Therapy Center, Inc., and the Wiley Center for Speech and Language Development. She has more than 50 years of clinical experience treating individuals with autism and their families from all over the world. Her wealth of clinical knowledge on autism spectrum disorder (ASD) intervention throughout the lifespan includes developing cutting‐edge programs to serve young adults with ASD during the transition out of high school. Her manualized approach, Autism, Attacking Social Interaction Problems (AASIP), has been used in social skills treatment in her centers and throughout the world. She holds the title of American Speech–Language–Hearing Association Honors, the highest award in our profession. We are grateful that she has taught us much of what we know today.
This textbook is meant to bridge the divide between theory and practice for students and/or new interventionists from any discipline who work with clients with ASD. Throughout the chapters, you will notice repeated references to terms like cultural competence and culturally responsive intervention practices. As speech–language pathologists of color, we believe strongly that cultural competence should be repeatedly considered in discourse about assessment and intervention with our clients and their families, who come from a myriad of diverse backgrounds.
We encourage you to continue learning long after you read this textbook. You should be informed by your professional discipline, clinical experiences, and continuing education as you use your clinical judgment to inform your best practices. To guide your reading, we have used a few different symbols and headings throughout the book:
Active Learning Task: This is a point where you and/or your instructor will look to promote active learning via activities designed to prompt your direct engagement with the material. This might include doing research, completing a brief activity, or writing a reflection. We encourage you to complete these tasks to interact with the textbook and deepen your learning.
Goal Spotlight: This symbol indicates a sample intervention goal you might use with a future client with autism. These are good opportunities to practice writing your own goals and/or developing treatment activities that might address the goal.
Therapy Golden Nugget: This indicates a practical suggestion for you to use in intervention. We include several of these ideas because many of our students and interns over the years have simply asked, “But what should I do?!” These examples are intended to get you thinking so you can begin to develop your own ideas for treatment activities to engage clients with autism across the lifespan.
Therapy Viewpoint
A Note on… It is our hope that this piece of work is cherished and will help to support a client with autism as they go beyond the label.
CHAPTER 1Historical Perspectives of Autism Spectrum Disorder
Learning Objectives
By reading this chapter, interventionists will be able to:
Compare and contrast diagnostic criteria for autism spectrum disorder (ASD) from the fourth edition of the
Diagnostic and Statistical Manual of Mental Disorders
(DSM‐IV) to the fifth edition (DSM‐V).
Identify a reason why girls with autism may be overlooked in comparison to their male counterparts.
Define the neurodiversity movement and ableism.
Compare the medical and social model of disability.
Before You Begin, Think About These Questions
What do I know about autism?
How did I first learn about autism?
What do I want to know about autism?
While criteria and descriptions have certainly evolved, ASD as we know it today is not vastly different from the way we knew it nearly 100 years ago when a psychiatrist, Leo Kanner, first wrote about his experiences with children with the disorder, all younger than age 11, beginning in 1938 (Kanner 1943). He published his longitudinal study as his counterpart Hans Asperger was writing of the same phenomenon, hence the former diagnostic term, “Asperger's Syndrome”. His seminal paper titled “Autistic disturbances of affective contact” described his experiences of 11 cases of children. Similar to the gender disparity we see today, Kanner included more boys than girls in his study.
As Kanner's study title suggests, the primary impairment of those children was social engagement, as all the children demonstrated deficits in key social domains including functional play skills and reciprocal social interaction. One case describes a child who “always worked and played alone” with “no manifestation of friendliness or interest in persons” and “no display of affection.” The descriptions clearly outline social communication deficits, in spite of typical IQ scores.
Cases often described various restricted and repetitive behaviors, a hallmark feature of ASD. Though written in 1943, descriptions could be included in diagnostic reports of the present day. For example, one case included the descriptions “stereotyped movements,” “repetitions carried out in exactly the same way,” and “verbal rituals,” which all could be used to describe common restricted and repetitive behaviors observed in individuals with ASD today.
What are the diagnostic categories for autism? In past years, a formal diagnosis according to the DSM‐IV had to involve three distinct categories:
Impairments in social interactions
Impairments in communication
Restricted, repetitive, and/or stereotyped patterns of behavior
Interests, and/or activities (
Table 1.1
).
TABLE 1.1 DSM IV categories used in the formal diagnosis of ASD
Social interaction impairments
Communication impairments
Restricted and repetitive behaviors
Marked impairment in the use of multiple nonverbal behaviors, such as eye‐to‐eye gaze, facial expression, body postures, and gestures to regulate social interaction.
Failure to develop peer relationships appropriate to developmental level.
A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g. by a lack of showing, bringing, or pointing out objects of interest).
Lack of social or emotional reciprocity.
Delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime).
In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others.
Stereotyped and repetitive use of language or idiosyncratic language.
Lack of varied, spontaneous make‐believe play or social imitative play appropriate to developmental level.
Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus.
Apparently inflexible adherence to specific, nonfunctional routines or rituals.
Stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting or complex whole‐body movements).
Persistent preoccupation with parts of objects.
Each category had to be identified to qualify for a diagnosis. Notably, the social interaction domain had to be identified twice as much as the other two diagnostic domains, highlighting the importance of social interaction deficits in the diagnosis of ASD.
Active Learning Task
Think, Pair, Share
Review Kanner’s 1943 publication. What were some of the descriptions of the cases of ASD in Kanner's seminal work?
How do those descriptions compare with our current knowledge of ASD?
Beginning in 2013, the DSM‐V collapsed the three diagnostic domains to just two domains: (i) deficits in social communication and social interaction, and (ii) restricted, repetitive patterns of behavior, interests, or activities. Essentially, the newest edition collapsed the social interaction and communication impairments into just one domain, rather than two independent categories, while maintaining the criteria for restricted and repetitive behaviors (Figure 1.1).
FIGURE 1.1 One domain for autism spectrum disorders.
So why was this change made? Researchers and clinicians alike readily identified social impairments and restricted and repetitive behaviors as defining features of ASD. However, readily identifying communication impairments was a challenging area even for professionals with significant experience with the population, particularly for diagnosing highly verbal individuals with little to no expressive and/or receptive language delays and typical IQ. These highly verbal individuals were often diagnosed with Asperger's, considered a “high‐functioning” version of autism. Even more controversial was a diagnosis of pervasive developmental disorder – not otherwise specified (PDD‐NOS), a label used to describe individuals who may have presented with autism‐like symptomology, but not enough characteristics to clearly receive an autism or Asperger's diagnosis.
Essentially, even the most experienced professionals were having difficulty reaching a consensus on these three diagnostic categories, with potential for one individual to receive three different diagnoses if evaluated by three different clinicians. This acknowledgment led to a shift in the perception of diagnosis and the idea of an autism spectrum, rather than a singular diagnosis. In fact, many current clinicians now more commonly use the term ASDs, indicating that autism is not just one single disorder, but actually several different types of disorders, each with a different presentation based upon symptom severity and expression. (Figure 1.1).
Why does this matter? As we discuss a bit later, appropriate, differential diagnosis is critical for individuals to be able to access appropriate services and to receive targeted interventions to best address their unique needs. The common refrain from Dr. Shore of: “If you have met one person with autism, then you have met one person with autism” remains accurate due to the vast heterogeneity of ASD. Research scientists in autism work to explore gene mutations in the disorder and recognize the likelihood of several different genetic markers, given the vast differences found in the heterogeneous disorder (Geschwind 2008). Of course, autism is not simply a genetic disorder. If it were, we could clearly test and identify it early on much like we do for other gene mutations, such as Down Syndrome, which we can identify in utero. Complexly, autism is thought to be a combination of pre‐existing genetic risk coupled with environmental factors. However, there still exists an element of the unknown that fails to explain the presentation of autism. For example, if there were only genetic and environmental factors, we might expect to see sets of twins both diagnosed and presenting similarly. That is not the case, despite siblings being at higher risk for diagnosis.
One of my most interesting patients was a four‐year‐old boy with autism who was nonverbal and had significant communication difficulties. He presented with ASD symptomology like hand flapping, difficulty with changes in routine, and significant social communication delays. His twin brother was the exact opposite. He was very social and loved to engage in play, often lamenting that he wanted to go to “speech class” because it looked fun and he never got a turn. They were a great example of siblings who shared the same genetic code and gestational environment as identical twins. It could largely be assumed that their environments after birth were also near identical. Yet, they did not both present with autism. The hardest question we are asked by parents is “What causes autism?” It is not hard because we are not well versed in the topic; it is hard because, like most clinicians, researchers, and scientists, it is difficult to say, “We do not completely know.”
It is important to consider that diagnostic criteria can change over time, often to create greater specificity and more standards for diagnosticians. Note how the criteria for a diagnosis for autism has changed over the past 40 years (Figure 1.2). Despite changes, note that the key elements remain stable over time: deficits in interaction skills with or without delays in language, and early presentation of delays.
FIGURE 1.2 Changes in the diagnosis of autism in successive editions of the Diagnostic and Statistical Manual of Mental Disorders.
CLINICAL CONSIDERATION
Some clinicians may have a fixed view of restricted and repetitive behaviors, which can prevent appropriate referral and diagnosis. Consider restricted and repetitive behaviors along a continuum that can include restricted and intense interests as well as verbal rituals, in addition to more commonly discernable presentations such as hand flapping. Consider the following examples:
Lining up toy cars
Intensely investigating objects at eye level
Difficulty adjusting to changes in routine
Insistence on discussing a particular subject with little regard for other topics
Immediate or delayed echolalia
Verbal rituals performed with the same script and intonation patterns
Hand or finger mannerisms.
Active Learning Task
Ask five different people, “What is autism?” Compare their responses. Do your respondents have any personal connections to ASD (do they know a person with autism)? How accurate is their response? What do they think the cause of autism is? Where did they get their information? Based on your findings, how can you go about better educating the general public on autism?
Clinical Anecdote
As a teenager in high school, I worked at a summer camp for children with special needs. One of the campers was a four‐year‐old boy who I adored. He was very chatty and loved riding bikes. One afternoon, I had him and two other campers in my car to head to a local park for a field trip day. As usual, I had taken a wrong turn and gotten lost (this was pre‐GPS, Waze, or Google Maps ). I pondered what to do aloud when suddenly my favorite camper in the backseat said, “Turn right on Centinela. Then make a left on Jefferson and a right on Bristol Parkway.” I chuckled, but then realized that was actually the way to get there. I mentioned it to his father later that day and his dad replied, “Oh he loves maps. He can honestly tell you how to get just about anywhere in the city. He doesn't play that great with other kids, but he is amazing at directions.” I later learned that the boy was diagnosed with autism. Subsequently, he became my permanent passenger on all camp field trips, with his penchant for maps camouflaging my horrible sense of direction.
A NEURODEVELOPMENTAL DISORDER: AUTISM AND THE BRAIN
Active Learning Task
Recall your studies in neuroanatomy. What are the key areas of the brain for:
Language?
Motor functioning?
Although we do not have an exact answer about what causes autism, we do know that individuals with ASD can demonstrate atypical neurological presentations in comparison with their typically developing peers and evidence suggests multiple interacting genetic factors (Muhle et al. 2004). While there is not a single, specific, genetic marker of ASD, evidence indicates that there are several different potentially impacted genes, which supports the theory of there being several autisms.
Research suggest that Purkinje cells, located in the cerebellum and thought to be responsible for motoric inhibition, are limited in individuals with autism (Whitney et al. 2008). Neurological deficits causing motor communication deficits have been explored as a factor for poor speech production in individuals with ASD (Mody and McDougle 2019). Studies indicate abnormal brain growth and enlarged cerebral gray and white matter in toddlers with ASD (Schumann et al. 2010). Further research into white matter indicates that children with ASD may rely more on visuospatial processing networks than their neurotypical peers (Sahyoun et al. 2010). Additionally, research suggests atypical function and organization in brain hemispheres among individuals with ASD, which may contribute to language delays (Kleinhans et al. 2008).
While most parents are less interested in the etiology and more interested in direct supports to promote communicative and social success for their children, it is important for interventionists to at least have an understanding of potential causes for autism. Inevitably, a parent will ask,
What causes autism?
How did this happen?
We should be able to counsel parents with accurate information and with empathy. It is important to note to parents that it is not anyone's fault. Autism is highly heterogeneous and differences in genetic factors and neural circuitry, along with environmental influences, all play a role in autism presentation (Rylaarsdam and Guemez‐Gamboa 2019). While we have yet to definitively identify all of the genes involved, research clearly points to the significance of the interaction of both genetic and environmental factors that contributes to autism risk (Chaste and Leboyer 2012).
THE CLINICAL TEAM: WHO AND WHAT
In working with individuals with ASD, it is critical to take a team‐based approach to promote holistic care that optimizes clinical strengths to promote achievement of optimal outcomes. The most important members of the treatment team, aside from the individual, are the primary caregivers, such as parents who are the first point of contact. Although there are several interventions available in the treatment of individuals with autism, it should be stressed that primary caregivers spend the most significant amount of time with their children, significantly more than any interventionist. As such, the importance of caregiver education cannot be stressed enough. All interventionists should incorporate caregiver education as a critical component of their intervention so that caregivers can continue to employ successful strategies in the home environment.
Interventionists serve as specialists within their respective domains. While each has a particular area of expertise, interventionists should strive for an interdisciplinary and collaborative approach in order to best treat autism from a holistic perspective. Collaboration is addressed in Chapter 11. The ultimate goal of treatment should be to promote communication and skills that permit the individual to live a fulfilling and independent life Figure 1.3.
FIGURE 1.3 Autism Spectrum Disorders.
Active Learning Task
What Is Your Scope of Practice?
Understanding the scope of practice outlined by your national organization is important when working with individuals with autism. The scope of practice tells interventionists what one should and should not be working on in your profession when working with individuals with autism. Using this document, write a one‐page reflection on the top three scope of practice areas you found interesting and/or never considered. Discuss these findings with your peers. Below you will find information surrounding scope of practice for specific professions working with individuals with autism. This list includes but is not limited to:
American Speech and Hearing Association
https://www.asha.org/practice‐portal/clinical‐topics/autism
American Journal of Occupational Therapy
https://ajot.aota.org/article.aspx?articleid=1865177
American Physical Therapy Association
https://www.apta.org/patient‐care/evidence‐based‐practice‐resources/clinical‐summaries/autism‐spectrum‐disorder‐in‐children
American Association of Pediatrics
https://pediatrics.aappublications.org/content/145/1/e20193447
American Psychological Association
https://www.apa.org/topics/autism‐spectrum‐disorder/diagnosing
Centers for Disease Control and Prevention
https://www.cdc.gov/ncbddd/autism/hcp‐dsm.html
Interventionists working with young children are encouraged to work with the end in mind. Be mindful that individuals spend significantly more time as adults than they do as children. Addressing maladaptive behaviors that significantly prevent individuals from learning and engaging with others around them should be targeted early using a direct approach, rather than a “wait and see” method. Developing and fostering unique skills that may be marketable as viable future job skills should be explored long before individuals are preparing to transition out of high school. This point is discussed extensively in Chapter 7.
NEURODIVERSITY
In consideration of adults, consideration should be given to self‐perception of individuals with autism. The neurodiversity movement challenges the deficit‐based approached of viewing autism and other neurodevelopmental disorders. Having grown over the last decades, proponents argue that autism is a variation along the spectrum of human differences, aligning autistics to other marginalized cultural groups (Jaarsma and Welin 2012). Scholars acknowledge that disability itself is a socially constructed concept, with the social model of neurodiversity arising as an alternative to the traditional medical model of disability (Figure 1.4; Krcek 2013). For a better understanding, see the “Social Model Animation,” which can be found on YouTube (Adams‐Spink 2011) to help increase understanding about how disability can be framed as a social construct. Ableism, which intersects with other systems of oppression, is defined as attitudes that discriminate and devalue people with disabilities; this includes the language we use to describe such individuals (Bottema‐Beutel et al. 2021). Interventionists working with individuals with autism and their families should be mindful of the language used to discuss clients and their areas of need, while also considering various perspectives of disability.
FIGURE 1.4 Medical and social models of autism.
Rather than viewing the individual with autism as someone in need of intervention to better adapt to societal conventions, leaders of the neurodiversity movement, such as those with autism and others, implore neurotypical stakeholders to get involved and champion changes that may better accommodate the needs of individuals with autism by normalizing autistic experiences (den Houting 2019). Supporters of this movement champion the rights of individuals with autism to speak for themselves. Additionally, the neurodiversity movement seeks to recognize neurological differences as variances that require more understanding, rather than treatment.
Active Learning Task
Consider the following scenarios through the approach of a medical model vs. that of a neurodiversity paradigm. Discuss how to address these challenges first through a medical lens (What kind of intervention would you employ?) and then through a social lens (What about the environment would you change?).
John is 13 years old and has significant difficulty in public spaces due to sensory sensitivity to noise, and bright lights.
Melanie is seven years old and has difficulty attending birthday parties. She loves blowing out candles and tantrums when she is not permitted to blow out the candle at peers' parties.
Importantly, this movement cites the need for individuals with autism to have a central voice in research. For example, in research led by individuals with ASD, Kapp et al. (2019) reframe the perspective of repetitive motor movements as an important adaptation and coping mechanism, rather than as a behavior to be eliminated. Such perspectives are important in considering that many interventions for autism are behavioral; scholars note the controversy between traditional behavioral therapies and the need for a more humanistic approach for interventions for ASD (Shyman 2016).
Highlighted in the movement are notable individuals with autism who have made significant societal contributions such as climate change activist Greta Thunberg, scientist Temple Grandin, and Kent State Division I basketball player Kalin Bennett. Autism itself is viewed as a strength, rather than as a disability. As such, many in this community prefer identity‐first language rather than person‐first language. This concept is usually the antithesis of what students are taught in schools, as most training programs would advocate for “person with autism,” rather than “autistic person” to use person‐first language. This difference in wording can be easily addressed by asking clients and their families what language they prefer or listening to how they identify themselves and then using language that respects their choice (Dorsey et al. 2020).
A NOTE ON LANGUAGE
Should I use person with autism or autistic person with my client? – Understand that both parents and clients can become offended if you use language inconsistent with their beliefs and/or self‐perception. While many professions advocate person first language, if unsure, ask your client and use their preferred language!
Some individuals with ASD who support the neurodiversity movement take issue with groups that support autism research, citing that research funding disproportionately supports efforts to find causes of autism and effective treatments, rather than funding efforts to support individuals themselves to make an active difference in their lives. Currently, much of the public efforts have begun to shift from solely autism awareness to autism acceptance, signaling the change to a more inclusive perspective. As a whole, established researchers have questioned if the neurodiversity movement will shift the full concept of disorders and intervention practices such as in psychiatry and other fields (Baron‐Cohen 2017).
Language describing individuals with autism has also changed. In the past, common terms to describe abilities included “low functioning” and “high functioning,” while current practices support describing abilities in reference to support and need such as “high support needs” or “low symptom severity.” Alternatively, some researchers may use “highly verbal” as opposed to “high functioning.” Similarly, many opt for “minimally verbal” instead of “nonverbal” to acknowledge those individuals who might have significantly limited verbal output but who still may present with some kind of verbal productions. Appropriate language is often evolving and interventionists should be mindful of current practices and reflect appropriate trends in light of changing information and preferences.
Additionally, many agencies have moved away from the use of imagery associated with autism, like the puzzle piece, as individuals with ASD have disputed the idea of autism as a puzzle or mystery to be solved rather than a person to be accepted and welcomed. Some current imagery may reflect other images such as an infinity symbol to represent the range of abilities and challenges in autism. Future imagery may consist of something completely different than what we see now. Overall, it is important to consider how our ideas and language about autism have transformed over the years and will likely continue to shift over time.
Research centered on reframing the social deficits in autism focus on evidence cited as the double empathy problem, which offers a counternarrative to common theory of mind deficits with findings that autistic people relate to each other much in the same way that neurotypical people relate to each other, despite the difficulty of interrelatedness between the two groups (Milton 2012; Mitchell et al. 2021). This idea presents the concept of autistic people as a minority group deemed “other” by a neurotypical majority. Such perspectives challenge ableist views that serve as the foundation of much of the medical community. Rather than solely considering ableist perspectives, the neurodiversity movement encourages people to consider diversity in social interaction skills rather than a binary right and wrong way of interacting with people. We encourage clinicians to consider this approach as all interventionists continue to evolve our understanding of autism and other neurodevelopmental disorders.
A NOTE ON TERMS
Aspie or Aspergian
This term may be used to refer to individuals formally diagnosed with
Asperger's syndrome
. Although this term is no longer used in current diagnostic criteria as of 2013 in favor of autism spectrum disorder
s
with accompanying levels of severity, many individuals who were first diagnosed with Asperger's Syndrome may still refer to themselves as such.
Autistic
Some clients might prefer
identity‐first language
(e.g. autistic person) as opposed to
person‐first language
(e.g. person with autism). If unsure, ask your client about their language preferences.
Masking
This term may refer to the
camouflaging
behaviors that some autistic people report doing in an attempt to fit in and/or make their autistic traits less noticeable. Often, clients report this masking behavior is tiring and requires considerable effort.
Neurodivergent
This term may be used to refer to individuals with autism and other disorders, while the term
neurotypical
may be used to refer to individuals without such disorders.
Stimming
This term often refers to
self‐stimulatory behaviors
credited as a restricted and/or repetitive behavior in the diagnostic criteria of ASD. Examples may include hand and/or finger mannerisms. Some autistic people report this behavior serves as a calming function to self‐soothe when anxious.
One fact that is not lost on us is that individuals with moderate to severe symptomology are not fully represented in the neurodiversity conversation as these clients who continue to struggle with independent communication may very well have their own opinions that remain unknown. However, we applaud the autonomy of individuals with autism having a strong voice in their own care, a right we do not believe that educators or allied health professionals would deny any client. As clinicians, we have received the neurodiversity movement as yet another way of conceptualizing of autism and we support the shift away from the deficit narrative. Emerging research support the concept of celebrating deficits as differences, a perspective that is more welcomed by those who self‐identify as autistic as well as those who report familiarity with the neurodiversity movement (Kapp et al. 2013). Some have warned of divisions spurred by the neurodiversity movement between those supporting autistic cultural identify and those with a perspective of the medical model of disability (Baker 2006). As future clinicians working with clients with ASD, we encourage you to consider the needs of your clients and their families, while not being tempted to view your clients from a deficit only approach.
SUMMARY
ASD is a complex neurodevelopmental disorder that centers around social communication challenges and includes the presence of restricted and repetitive behaviors. Causes of autism include genetic and environmental factors, although the complete cause remains unknown. The DSM‐IV had three diagnostic domains required to meet diagnostic criteria for diagnosis: restricted and/or repetitive behaviors, communication, and social interaction challenges. The DSM‐V reduced the diagnostic criteria to two domains and collapsed the domains of communication and social interaction to form the criteria of social communication. Current views support the idea of several disorders classified as an autism spectrum rather than former separate diagnostic categories such as PDD‐NOS and Asperger’s. Optimal treatment of ASD includes a collaborative approach between several disciplines with respective expertise. Treatment of ASD should focus on promoting communication and independence. The neurodiversity movement offers a perspective that includes more acceptance of neurological variance. The voices of individuals with autism should be included in their own care. This can be accomplished in part by valuing first‐hand accounts, centering the scholarship of researchers with autism, and reconceptualizing the ideas of autism to prioritize strengths of individuals, rather than deficits.
REFLECTIONS ALONG THE PATH
Connie Kasari, Ph.D.
I began working with children with disabilities in the late 1970s/early 1980s. We were just starting to work with severely delayed children, who had limited services and support. I was very involved in Child Find efforts, because at the time, school‐aged children with disabilities were not given an opportunity to attend public school programs. That changed in the late 1970s with the passage of PL 94‐142 (the Education for All Handicapped Children Act of 1975). Now that all children could gain access to school, we worked hard to locate children, often with the most severe disabilities, and to bring them into school settings. As educators, we also began working with infants and toddlers with disabilities, who previously were only seen by medical professionals. It was an exciting time of developing services for children with disabilities, and connecting families and children to these needed services.
I started out in a metropolitan area in the southern United States, working primarily with low‐income, minority families and their severely disabled infants under the age of two years. All of these children and families were amazing, but one child in particular stood out to me. It was a little girl just under two years of age. Her developmental profile was very perplexing. She was not interested in toys or engaging with people. We could teach her something one day, but she would not show the skill again; or she learned something in one setting but could not demonstrate it across settings (like home and school). I now recognize that the child likely had autism, but at the time, I knew very little about this condition. Our team was very unprepared to help this child and her family, and I often think back to her now that we know so much more about interventions for children with autism.
I have spent my career trying to understand the core social communication difficulties of these children, and I have developed interventions to address their needs. Thirty years ago, when I began, three‐quarters of children entering kindergarten were minimally verbal; today only about 30% of children remain minimally verbal. The field has made tremendous progress, and yet, we still have much more to learn. Today, I am involved in the combination and sequencing of interventions, to better personalize interventions for individual children. One thing we have learned is that a single intervention is not effective for all children, and that many children will benefit from several different interventions that are more or less intense during different phases of their development.
This recognized heterogeneity in autism also propels us to think about the children who are often left out of research studies, including minimally verbal children, and those with intellectual disability, females, low income, and ethnic‐minority children. We need to do a better job of developing interventions that fit their needs. To do this work well, we also need to have a more diversified work force, one that reflects the cultural and linguistic needs of our population. I hope we can attract a broad and diverse new group of therapists who will see the potential in each and every child, and work to systematically personalize effective interventions.
Connie Kasari, Ph.D.
Professor of Human Development and Psychology and Professor of Psychiatry
University of California Los Angeles
TEST QUESTIONS
According to the DSM‐IV, an ASD diagnosis was evaluated by ___ domains.
2
3
4
5
According to the DSM‐V, the diagnostic criteria for ASD include the following categories except:
Restricted and repetitive behaviors
Social communication
Social interaction
All of the above
According to the DSM‐V, an ASD diagnosis includes ___ key domains.
2
3
4
5
Which of the following is true about sex differences in ASD diagnostic rates?
Boys are diagnosed more than girls
Girls are diagnosed more than boys
Boys and girls are diagnosed at the same rate
Gender data about ASD diagnostic rates are unknown
Leo Kanner authored his seminal work about ASD in what year?
1984
1954
2002
1943
Restricted and repetitive behaviors may include all of the following except:
Verbal rituals
Difficulty disrupting routines
Self‐injury behaviors
Difficulty maintaining eye gaze
In the autistic community, some clients may prefer identity‐first language (autistic person) as opposed to person‐first language (person with autism).
______ are camouflaging behaviors that some autistic individuals may use to better fit in with neurotypical people.
Masking
Stimming
Echolalia
Facial grimaces
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