These notes begin with further evidence and advice about the promotion of social interaction among pre-school children with autism, emphasising the role of the adult in following and imitating the child’s lead.
The next section summarises advice about enhancing adaptive behaviours among older children with particular regard to communication and socialisation.
There follows a section on the use of (atypical) medication in managing and reducing autistic behaviours and symptoms.
The final section concerns the nature and management of stereotyped behaviours where intervention appears most effective when a (functional) assessment is followed by a combination of strategies.
M.J.Connor July 2007
Social Engagement among Pre-school Children
The study by Wimpory et al (2007) starts by acknowledging
that, among children with autism, a major and defining characteristic is the
lack of affective contact and interaction with others.
This is all the more significant in the light of converging evidence that social engagement is a critical first step in the development of context-sensitive thinking and of language.
Accordingly, their own research has examined the nature of the ongoing interactions between adults and preschool children with a view to determining whether there are particular elements or qualities of the adult behaviour which increase the probability of social engagement with the children. (They defined “episodes of social engagement” – ESEs – in terms of child behaviour, such as a look towards the adult’s face, indicative of moments of active responsiveness.)
The authors further describe the nature of social impairments in autism as a matter of frequent failure to orientate to, or respond to, social input or the personal-affective overtures. When some response is observed, it may still lack reciprocity such that there is no real bi-directional exchange.
This pattern is described as evident from a very early age and largely continuing throughout the life span; and diagnostic cues are drawn from parental reports of a lack of eye contact among very young children, or an absence of any meaningful person to person interaction (such as pointing to objects as a means of initiating shared attention and experiences).
On the other hand, they continue, for many children with autism, these deficits are relative rather than absolute; and there may be glimpses of apparently true sociability.
It is also noted that scope may exist to reduce these limitations and anomalies in interpersonal relatedness, especially if such efforts are exercised among very young children …. and reference is made to the evidence from various studies over many years that greater responsiveness is associated with an active and structured input and when the adult actions follows or imitates … ie is contingent upon … the child’s actions.
For example, Field et al (2001) reported on an increase among children with autism of eye contact and of the visual monitoring of an adult, plus other social behaviours such as pointing or gesturing, when the adult imitates the child’s own behaviour.
(In other words, social interaction may more readily be initiated when the adult joins the child’s world and seeks to share the child’s activities than when attempts are made to attract the child’s attention to some activity or object presented by the adult.)
A similar finding was reported by Siller and Sigman (2002) in that older individuals with autism showed superior joint attention and language when, as young children, they had experienced a high level of adult synchronisation of this kind during their free play.
Accordingly, Wimpory et al used videotapes of one to one play-based assessments in clinical settings in order to identify the emergence of ESEs … active involvement of the child with the adult … and to highlight the actions of the adult immediately before these events such as the following of the child’s focus of attention, imitation, and repetition which all take up or elaborate upon the child’s actions as opposed to seeking to direct the child’s actions.
Their sample comprised 19 boys and 3 girls aged between 2 and 4 years, all diagnosed with autism. The observations were made during assessment sessions using play procedures in centres equipped with a range of toys and materials for gross motor, fine motor and imaginative play.
The assessment sessions included times when the adults made attempts to follow the lead of the children, and times when they operated in a more passive way to see if the child would or could spontaneously initiate interaction. Some activities were designed to gain a measure of cognitive capacity, others to investigate an interest in pretend play.
Opportunities were created to engage in action rhymes, or rough and tumble play, along with attempts to elicit proto-declarative gestures (pointing to share something) and proto-imperative gestures (pointing to request something).
ESEs were defined as events where the child looked at the adult and showed some further form of communicative action such as giving or taking an object, touching the adult, turning towards the adult, smiling, gesturing, making sounds with a toy, and vocalisations.
The adults’ behaviours were recorded according to two elements.
Activity referred to the intended form of engagement through pretend play, or the use of cognitive activities such as puzzles or inset boards, or musical and motor activities such as using a toy instrument or singing or playing in the sand tray or on a slide, or inactivity involving a deliberate passivity.
Communication referred to continuing any verbal or physical action engaged in by the child, or seeking to redirect the child’s actions or attention, or giving a silent attentiveness to the child, or appearing to ignore the child.
The observation also included the precise nature of the “scaffolding” provided by the adult …
The results supported the prediction that ESEs would be linked with the higher prevalence of adult behaviours such as observable activity in musical or motor forms, in maintaining the communicative “continuer” role, and in scaffolding social routines, imitation, and self-repetition.
It was also found, as predicted, that ESEs did not follow adult behaviour involved in the adult presentation of cognitive activities, attempts to redirect communication, inactivity, or ignoring the child.
Meanwhile, the emergence of ESEs appeared unrelated to the adult actions involving pretend play and silent attentiveness.
On the other hand, imitation combined with self-repetition did appear to have a greater impact than imitation alone.
In their discussion, the authors highlighted the support gained for the view that social engagement of children is significantly related to the style of adult behaviour and interaction.
In particular …..
The authors emphasise the value of musical and motor activities, and those that pick up and continue the child’s own activity as opposed to those that attempt to redirect the child’s actions and which involve a silent response or actual ignoring.
They acknowledge that the apparent contingency between adult and child behaviours assumes a direct functional and causal relationship; and they also recognise that the quality and depth of the engagements described are hardly comparable to those of children without autism, and scope remains to explore the longer term outcomes in the case of young children with autism who do display more frequent or more intense episodes of these basic engagement behaviours.
However, the implication is for the provision of a high level of support as a means of compensating for the social deficits among children with autism through these active strategies where the adult follows the child’s lead. It is the adult’s adjustment to the child’s style and orientation that may be key in promoting social engagement.
Strategies for Enhancing Adaptive Behaviours
The review by Preis (2007) assesses the effectiveness of interventions for children with autism, with an emphasis upon communication and socialisation (likely to have a major impact upon adaptive functioning), while recognising that some approaches which have enjoyed popularity may not have the support of empirical evidence.
Preis argues that an important first step in the planning of an intervention is an adequate assessment (both base-line and ongoing) although she also notes that the significance of “assessment” appears often to be under-rated in some educational or clinical settings.
It is recognised that the reality of day to day commitments may be at odds with the ideal of thorough and functional assessments, but it remains important to have a clear idea of what the children can do as oppose to focusing upon a list of their children’s deficits.
Further, any assessment should involve the input from different professionals as well as the parents in order to gain a clear picture of strengths and weaknesses in various domains and their expression in different settings and according to different contextual demands. The need, in other words, is for a continually updated picture of performance by which to inform the planning of strategies matched to the hypothesis about how a given individual can achieve successful outcomes.
Preis discusses “antecedent interventions” which are designed most effectively to achieve an accommodation of the classroom setting to the child or young person (as opposed to expecting that he or she will accommodate to it).
These will include a matching of developmental level to modifications to the classroom circumstances and demands in terms, for example, of individual work stations, specific schedules, and the way demands are presented or are to be acted upon …. all with a view to promoting independence and eventual self-sufficiency.
(One might interject here to highlight the point that simple exposure to social or learning models in the case of children with autism, or with other needs, is unlikely to be sufficient in itself to achieve an assimilation of the behaviours and routines in question…rather it is a matter of direct and implicit teaching, and of structuring the setting to match individual profiles of strengths and needs, with a gradual fading of the support and cues and prompts as the routines are “internalised”.)
The author lists the various ways in which the children may be differentiable from non-autistic children, or from one to another, including impairments in expressive and receptive language, attention, the capacity to cope with abstractions, auditory processing, organisation, generalisation, and shifts in activities and routines.
Strengths may include visual processing, a focus upon detail, specialised interests, and rote memory.
The example of an effective structure is that set out by the TEACCH principles where different locations for different tasks are used, thus to develop a recognition of an association between specific settings and events, and of the relevant expectations.
Another major variable is the size of any given step of a task (or of the task itself), and the sequences of steps, together with careful insertion of new demands within acquired and familiar actions, thus to reduce anxiety and the probability of negative behaviours … ie to counter any likely stress at the presentation of new demands by adjusting the scope of that new demand all within an atmosphere of positive feedback in respect of successful repetition of already acquired skills or bits of knowledge.
It may be necessary to utilise some particular interest of the student in order to introduce a learning theme, and to be aware of individual differences in what the children find attractive as reinforcers, in the long term goal of enabling the children and young people to gain a sense of achievement.
(One might interject again and suggest that this is not different in kind from the way one might organise the teaching and learning of any group of children, but the difference is in degree … for example, in the size of steps, the availability of reassurance, the explicitness of the instructions or the demonstration, the time for consolidation, and the direct pointing out of the link between the current step of a task and the previous.)
As with any child, it is likely that an enhanced choice of activities, or of the order of activities, will be reflected in a reduction in maladaptive behaviours.
Preis then refers to the common difficulties among individuals with autism in processing certain sensory information, or in tolerating noise or distractors, or coping with multiple inputs and with certain “qualities” of the sensory stimuli such as texture.
The individual preferences and tolerances need to be determined thus to be able to plan compensatory or averting strategies, such as softer lighting, carpeting, particular colour schemes, etc.
Some children would benefit from the introduction of new bits of learning in one to one settings, or removal from activities or settings where the noise level is likely to be high.
Meanwhile, the relative visual strengths or preferences can be used with a view to ensuring a predictability of events. Timetables set out in pictures, and icons to act as reminders or cues, can have this effect especially given the report that information conveyed in pictures is more likely to be noted and remembered than verbal information.
The visual information may include daily tasks, calendar information, the sequence of activities for a given day, choice boards, signs to direct behaviour, and photographs of places and people to increase their familiarity or photographs of the individual engaged in a particular activity as a reminder and reinforcer of the appropriate action.
In respect of communication, the advice recognises the variation in the nature and level of the deficits across individuals and across a range of elements such as phonology, syntax, semantics, and pragmatics.
Communication is perceived as a critical basis for a range of other skills, including social skills and interaction, with level of language competence seen as a major predictor of general performance and long term outcomes.
This being so, the need is for a clear documentation of the child’s strengths and deficits, along with a recognition of the extent and nature of the communicative intent of pre-verbal and verbal behaviours. The implication includes assessing the basic elements of communication, including the readiness to share attention, to take turns, and to imitate.
The question that needs to be asked concerns what the child is trying to convey by his behaviour … what (s)he needs, or whether there is something causing stress and anxiety (ie an interpretative and functional analysis of verbal or non-verbal behaviours). Having established the focus or foci of these behaviours, which may be having a maladaptive impact, the goal is their replacement by some simple communicative system (such as the use of cards) or the averting as far as possible of the identified arousing or frustrating circumstances.
Reference is made to the ABC of behaviour … the antecedent, the action, and the consequence … although one might suggest that care is taken to determine as far as possible what is the antecedent as perceived by the child or young person with autism which may be open to modification.
Preis reviews evidence to indicate that problem behaviours can be reduced or removed by the strengthening of communication skills. This may apply particularly to those behaviours whose function is to gain attention or an escape from a situation which is experienced as difficult or stressing.
In respect of those children who are without any meaningful form of language, ie no speech and limited skills in its precursors (such as minimal sharing of attention or monitoring of gaze), the use of discrete trial teaching approaches may be indicated. The drill approach offers a focus upon, and consolidation of, specific communicational “bits” via much repetition and reinforcement.
For some children, there is reference to the relevance of “incidental” or “milieu language” teaching.
Incidental teaching involves the utilisation of naturally-occurring interactions in order to foster communication. The starting point is the child’s choice of a focus of attention or interest with a series of graduated prompts by which to shape the child’s behaviour.
Milieu teaching combines this kind of incidental teaching with modelling the response expected from the child, and the use of a time delay in respect of the emergence of the child’s response, all within some natural setting and ongoing interaction.
Both discrete trial teaching and milieu teaching can be effective, but the former may be more appropriate for children with the more limited basic skills, while the latter’s focus upon actual events and more natural reinforcers have greater impact upon both language development and the enhancing of positive affect/rapport.
Turning to socialisation, it is recognised that component requirements include the ability to initiate and maintain interactions with others, to understand appropriate cues and feelings, to regulate one’s own behaviour, and to make appropriate choices of (social) behaviour.
Direct and explicit intervention is called for since, as commonly noted elsewhere, simple association with non-autistic peers does not in itself ensure enhanced social skills (or even social interest) on the part of the children and young people with autism.
Nevertheless, specific teaching and demonstration and practice of social skills become more meaningful and immediate in a setting which does allow for interactions between individuals with and without disabilities. Peer-mediated techniques can be effective, but this requires instruction about how to make and maintain interactions for both the pupils with autism and for their peers.
What seems to matter is the focus upon real situations and issues for which specific behaviours and responses can be taught and practised in a range of settings and with different peer partners/groups.
“Vertical” development refers to the need to be aware of the increasing complexity and subtlety of social interactions as the individuals get older with a need, therefore, to have consolidated the basic skills and for teachers and mentors to maintain an awareness of successive issues and potential conflict points.
Also relevant here would be social skill groups, again involving a mix of participants, social stories, continued use of picture cueing to predict events and give notice of changes or of sequential steps for the completion of a task, and video modelling.
Social stories are seen as useful in providing the language to cover the situations that individuals find stressful and a series of steps plus a self-reassuring script by which to increase social behaviours.
Preis concludes by restating the need for an initial and functional assessment of performance and ongoing reviews, and the individualisation of goals and strategies.
Generalisation is a further consideration with steps towards this target to be built in, via practice in different settings and with different partners or groups from as early as possible.
Atypical Medication (Anti-psychotics) in Treating Symptoms
The overview concerning the safety and efficacy of certain forms of medication, referred to as atypical anti-psychotics, and produced by Stachnik and Nunn-Thompson (2007), was based upon a literature search involving clinical trials case reports, and retrospective series.
Their report begins with a definition of autism and pervasive developmental difficulties (PDD) as a group pf severe and heterogeneous neurodevelopmental disorders impacting upon behaviour and social characteristics. The emphasis is upon the communication of feelings, social interaction, and reciprocity of relationships.
A broad range of presentations are classified under PDD, including classic autism, Asperger syndrome, Rett syndrome, childhood disintegrative disorder, and “pervasive disorders not otherwise specified”.
They note that causes remain unclear, although there is evidence for a strong genetic component, and for the involvement of anomalies in the operation of certain neurotransmitter substances. Some atypical brain structure or dysfunctions have been reported; and environmental factors may impact upon some underlying propensity to bring about the emergence of symptoms …. (such as, one might say, the use of the MMR vaccine about which there remains some aetiological suspicion despite the body of empirical evidence contrary to this particular hypothesis).
These authors go on to describe how interventions are based upon the particular profile of symptoms, such as anxiety, social withdrawal, aggressive behaviour, repetitiveness, etc.; and the medications that are frequently prescribed for children include stimulants, antidepressants, mood stabilizers, and those acting upon specific neurochemical systems.
They describe the use of atypical antipsychotics as being based upon their observed efficacy in respect of certain psychiatric disorders whose behavioural symptoms are similar to the core features of autism. These include olanzapine, ziprasidone, quetapine, and aripiprazole.
The general conclusion following the review of studies concerned with the use of these four agents is prefaced by a reminder that only risperidone has been formally approved for use in autistic disorders, and that no specific guidelines exist for the pharmacological treatment of the severe behavioural problems that may be observed among individuals with such disorders.
However, it is acknowledged that this kind of intervention can reduce the behavioural symptoms thus enabling a greater integration within peer groups and a better quality of life for the individuals themselves and their families.
On the other hand, there is concern about the likelihood of adverse side effects, such as weight gain or other metabolic problems, sedation, and possible impacts upon the cardiovascular system.
The authors recognise that a major limitation associated with the various reports surveyed is the lack of rigorous controls and of randomised groups, or the lack of consistency and direct comparability of outcome measures.
Therefore, while reporting that the use of the medications listed can bring about positive changes in behavioural symptoms, such as hyperactivity, aggressiveness, and self injury, (as illustrated by more positive ratings of behaviour compared to baseline ratings), they report also that there is no benefit in terms of an impact upon the core symptoms of the autistic disorder.
Their conclusion is that these medications may, on the basis of further (controlled and systematic) studies, prove to be a legitimate option for symptoms linked with autistic disorders, but that the long term safety and efficacy are not yet established, the core characteristics of the disorder appear unaffected, and adverse side effects may prove significant.
Accordingly, the advice is for great caution when considering any suggestion about their possible use among children and young people with autism, and for awaiting the outcome of long term clinical trials which will determine whether or not they might be generally recommended for use in dealing with chronic (behavioural) symptoms.
Managing Stereotyped Behaviours in Autism
A general review, describing the characteristics of repetitive, stereotyped behaviours
(RSBs), possible mechanisms, and interventions, was completed by Hendren et al (2007).
They begin by noting how RSBs were included in Kanner’s original description of autism in 1943, and Asperger’s account in 1944. They are essential and defining features of autism … albeit not unique to autism but observed also in other conditions such as obsessive-compulsive disorder (OCD).
The significance of these behaviours lies in the various negative outcomes such as peer rejection or, at least, impaired social interactions; self-injurious behaviours; frustration among parents and carers; and an inhibition of exploratory play with negative implications for learning and (cognitive and social) development.
DSM-IV describes RSBs as preoccupations with stereotyped or restricted patterns of interests that are abnormally intense; an inflexible following of set routines and a resistance to change; repetitive motor mannerisms; and persistent focusing upon particular objects or parts of objects.
While RSBs and OCD appear to have some common features, such as the significance of anomalous structure or functioning within the caudate region of the brain, they can be distinguished in terms of qualitative differences in the nature of the repetitive thoughts and behaviours.
For example, McDougle et al (1995) are quoted as noting how autistic adults are more likely to engage in repetitive ordering, hoarding, telling/asking, touching, and self-injurious actions. Those with OCD are more likely to demonstrate obsessive cleaning, or checking, or counting. Further, such behaviours in autism may act as a source of pleasure, but may represent a source of anxiety and quest for reassurance among people with OCD.
While repetitive behaviours are relatively common among young typically-developing infants, the continuing demonstration of RSBs is one feature by which to identify children with autism.
The stereotypy may be perceived as one of two broad types. “Lower-level behaviours” are characterised by repetitive movements, while “higher-level behaviours” involve preoccupations, an insistence upon sameness, and restricted patterns of interests. Turner (1999) held that the higher level behaviours are more specific to autism, while the lower level behaviours may relate more to developmental delay and intellectual impairment.
As far as the nature and purpose of RSBs are concerned, a number of theories have been put forward.
A theory concerned with homeostasis holds that these behaviours represent an attempt to maintain an optimal level of sensory stimulation, warding off excess levels while ensuring that the input is constant and consistent.
Another view has it that the behaviours are maintained through operant conditioning.
Social theorists would argue that the RSBs are a form of coping strategy by which to reduce anxiety associated with the social impairments and the consequently confusing and threatening world of relationships where the thoughts or motives of other people cannot be appreciated. The behaviours provide a safe and predictable world into which the individual may retreat when anxiety is building, or when (s)he lacks the social cognition by which to maintain an interaction. In the same vein, it has been argued that the behaviours are a means of compensating for the social isolation.
Further, the very sameness of the RSBs reflects an attempt to introduce predictability into a world where events and the actions of other people are not predictable.
In respect of the “tangible” source of these behaviours, the authors cite evidence from neuro-imaging studies that impairments in brain circuits involving the basal ganglia or right caudate and putamen are implicated in repetitive and stereotyped (motor) activity. There is the further suggestion that dysfunction in frontal lobe processing is implicated in respect of a failure adequately to filter and prioritise incoming stimuli such that the individual faces an overwhelming mass of sensory input from which some relief is sought.
Interventions which have been demonstrated to have some useful impact include the application of a functional assessment of the behaviours thus to identify the circumstances which consistently precede the RSBs and which may prove to modifiable (or the individual’s sensitivity towards the identified issue or situation may be open to reduction).
Meanwhile, evidence is cited that an emphasis upon positive reinforcement for appropriate behaviours is more effective than a programme which includes an element of negative reinforcement (punishment).
The advice concerning medication has it that this approach would best be tried only when a behavioural programme alone has had limited success. The use of medication would not replace, but would operate alongside, the behavioural intervention. There is a reiteration of the note of caution about pharmacotherapy with children given the limited data about safety and efficacy.
Serotonin reuptake inhibitors have become a frequently-used medication for many mood and anxiety disorders, given their relatively low rate of reported side effects, and increasingly are considered for the management of RSBs with some evidence cited for their success in reducing these behaviours as well as other maladaptive symptoms in children and in adults. The existing evidence is seen as justifying larger scale trials among samples of children within clear diagnostic/symptomatic categories.
The authors conclude by restating the significance of RSBs even if existing research studies in autism have tended to place their emphasis on other characteristic elements.
What matters is that intervention is planned according to a thorough assessment, including an exploration of the likely function of the behaviours observed, and involves an amalgam of behavioural approaches, education for the family, input from special educational professionals, input from other specialists as required (such as speech and language specialists or occupational therapists), and pharmacotherapy also as required.
* * * * * *
M.J.Connor July 2007
Field T., Field T., Sanders C., and Nadel J. 2001 Children with autism display more social behaviours after repeated imitation sessions. Autism 5 317-323
Hendren R., Horst R., White R., and Saenger E. 2007 The challenge of changing stereotyped behaviour in autism. Medscape Continuing Education. Medscape : June 28th
McDougle C., Kresch L., Goodman W. et al 1995 A case-controlled study of repetitive thoughts and behaviour in adults with autistic disorder and obsessive-compulsive disorder. American Journal of Psychiatry 152 772-777
Preis J. 2007 Strategies to promote adaptive competence for students on the autism spectrum. Support for Learning 22(1) 17-23
Siller M. and Sigman M. 2002 The behaviours of parents of children with autism predict the subsequent development of their children’s communication. Journal of Autism and Developmental Disorders 32 77-89
Stachnik J. and Nunn-Thompson C. 2007 Use of atypical antipsychotics in the treatment of autistic disorder. Annals of Pharmacotherapy 41(4) 626-634
Turner M. 1999 Repetitive behaviour in autism; a review of psychological research. Journal of Child Psychology and Psychiatry 40 839-849
Wimpory D., Hobson R., and Nash S. 2007 What facilitates social engagement in preschool children with autism ? Journal of Autism and Developmental Disorders 37 564-573
© Mike Connor 2007.
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