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Theories – Assessment from the view
of Speech and Language Clinical Practice for children/ young people with ASD
Θεωρίες – Λογοθεραπευτική Αξιολόγηση
παιδιών/ νέων ατόμων με Διαταραχές Αυτιστικού Φάσματος
Anastasios M. Georgiou
Αναστάσιος Μεν. Γεωργίου
Abstract
Autism is the result of a
neurological disorder that has an effect on normal brain function, affecting
development of the person's communication and social interaction skills. The
aim of SLT assessment is to gather and record information that enables
diagnosis. Such an assessment is necessarily comprehensive and might take place
over a period of time. The process of assessment aims to review functioning in
relevant domains and facilitate intervention. Specialist assessment in general
should include a history-taking element, a clinical observation assessment
element, and the obtaining of wider functional information. Almost anyone
diagnosed with an autism spectrum disorder will be recommended for speech
therapy. Speech therapy involves much more than simply teaching a child to
correctly pronounce words. In fact, speech therapists who deal with autism,
work on diverse linguistic areas in which people with autism have difficulties
regarding acquisition and generalization.
Περίληψη
Ο Αυτισμός είναι το αποτέλεσμα μιας
νευρολογικής διαταραχής που έχει επίδραση στη φυσιολογική λειτουργία του
εγκεφάλου, επηρεάζοντας την επικοινωνία και τις δεξιότητες κοινωνικής
αλληλεπίδρασης του ατόμου με αυτισμό. Ο στόχος της λογοθεραπευτικής αξιολόγησης είναι η
συγκέντρωση και καταγραφή πληροφοριών που προάγουν τη διάγνωση. Μια τέτοια
αξιολόγηση είναι απαραιτήτως εξονυχιστική και μπορεί να είναι και χρονοβόρα. Η διαδικασία αξιολόγησης έχει ως στόχο την
εξέταση της λειτουργικότητας του ατόμου και τη διευκόλυνση της παρέμβασης. Γενικότερα, οι αξιολογήσεις των ειδικών πρέπει να
περιλαμβάνουν τη λήψη ιστορικού, την κλινική παρατήρηση, καθώς και την εξασφάλιση
ευρύτερων πληροφοριών. Σχεδόν οποιοσδήποτε διαγιγνώσκεται με διαταραχή φάσματος
του αυτισμού παραπέμπεται για λογοθεραπεία. Η λογοθεραπεία περιλαμβάνει πολύ
περισσότερα από την απλή διδαχή της ορθής προφοράς των λέξεων. Στην
πραγματικότητα, ο λογοθεραπευτής που ασχολείται με αυτισμό ασχολείται με
ποικίλους τομείς της γλώσσας, στους οποίους τα άτομα με αυτισμό παρουσιάζουν
δυσκολίες ως προς την κατάκτηση και τη γενίκευσή τους.
Introduction
Autism stems from the Greek word "autos" which means
"self." The term was firstly introduced by a Swiss psychiatrist named
Eugene Blueler in 1912. He used the term in order to describe schizophrenic
patients who were in catatonic states. Bleuler referred to solitariness and
withdrawal that those people exhibited.
The classification of autism did not occur until the middle of the
twentieth century, when in 1943 psychiatrist Dr. Leo Kanner of the
An Austrian scientist named Hans Asperger described children in his
practice who lacked nonverbal communication skills, demonstrated limited
empathy with their peers, and were physically clumsy. The majority of his work
wasn't widely read until 1997 and was not translated in English for almost 50
years. Gena [11] argues that autistic disorder or Autism comprises a type of
Pervasive Developmental Disorder and has been defined as a “spectrum” disorder,
with the term “spectrum” indicating the variation in the clinical phenotype
observed. Firth [10] notes that autism influences the whole mental development
and under no circumstances should it be perceived as a static situation since
as time passes, the same person exhibits different autistic traits.
According to DSM-IV (1994) [16] the prevalence of autism is estimated to be approximately 2-5:10000
children, 3-5 boys: 1 girl. However, according to the Center for Disease Control and Prevention (1997) prevalence is estimated
to be approximately 1:10000 children.
Etiology of autism
Autism breeds “decrease” in: reciprocal social interaction, verbal –
nonverbal communication, general behavior, interests, activities. In the above
domains, people with autism do not always differ because of a delay in the
process of development, but they exhibit deviant behavioral patterns which are
not observed in typically developed individuals [10]. Fundamental impairments
of social communication tend to persist throughout life! Although autism influences the whole
mental development, under no circumstances should it be perceived as a static
situation since as time passes, the same person exhibits different autistic
traits [10].
Before 1970 (i.e. Αsperger, 1944; Bettelheim, 1967; Κanner, 1943) scientists believed that autism was a
consequential condition of parental neglectfulness (environmental-
psycho-genetic explanation of autism). However,
more recent studies demonstrated the insufficiency of such theories, since they
provided potent arguments of genetic contribution to this condition (e.g.
Baron-Cohen, 1995; Brothers, 1999; Gilberg, 1983; Ritvo et al., 1985 Szatmari
& Jones, 1991). Nevertheless, autism
is a complex neurodevelopmental disorder and as Gena [11] argues, it is unknown
whether autism is a unique entity regarding its aetiology, or else comprises
the expression of multiple complex causes.
Theory of Mind (ToM) (Baron-Cohen 1995; Baron-Cohen, Leslie, & Frith 1985)
Having a theory of mind is to be able to reflect on the contents of
one’s own and other’s minds [4]. When we mind-read or mentalize, we not only
make sense of another person’s behavior (Why did their head swivel on their
neck? Why did their eyes move left?), but we also imagine a whole set of mental
states (they have seen something of interest, they know something or want
something), and we can predict what they might do next [3].
In a great deal of studies (e.g.
Baron-Cohen, Leslie & Frith, 1985; Baron-Cohen, Leslie & Frith, 1986;
Leekam & Perner, 1991; Perner, Frith, Leslie & Leekam, 1989; Reed &
Peterson, 1990; Swettenham, 1996; Swettenham, Baron-Cohen, Gomez & Walsh,
1996) [4] it is argued that children with autism have difficulties in shifting
their perspective to judge what someone else might think. What do they do instead? They just report
what they themselves know.
The theory of mind model has its limitations in explaining autism [8].
Children with Asperger's syndrome are not more competent in theory of mind
tasks than children with autism within the normal range of intelligence.
Therefore, we need to review whether the classification of autism on the basis
of symptoms exists. Besides, we expect the publication of DSM-
The Empathizing-Systemizing Theory (Baron-Cohen, 2002)
Two parameters are taken into account: empathy (below average) and
systemizing which is a psychological factor (either average or even above
average). Systemizing is the drive to analyze or construct systems (any kind,
e.g. abstract, natural and technical). In other words when we systemize we have
knowledge of the rules which govern the system, in order to predict how that
system will behave (Baron-Cohen, 2006). When we systemize we know the rules and
regularities (structure) of a system.
Prows of the E-C theory [3]
This is a two factor theory.
In other words it explains both social and nonsocial traits in autistic
spectrum conditions. Below average empathy is a simple way to explain the
social and communication difficulties, whilst average or above average
systemizing explains the narrow interests, repetitive behavior, and resistance
to change/need for sameness. Furthermore, it does not focus only on the areas
of difficulty (empathy) but also on the areas of strength (systemizing) in ASCà ASD is
viewed as a difference in cognitive rather than as a disease.
Poor executive functioning [12]
Executive function comprises planning
working memory, impulse control, monitoring of action etc. All are thought to
depend on systems that involve prefrontal activity in the brain in normal
individuals. In autism poor
performance is observed in many tests related to executive function (e.g.
Rumsey & Hamburger 1988; Szatmari et al. 1989; Prior & Hoffmann
1990; Ozonoff et al. 1991; Ozonoff & McEvoy 1994; Ozonoff 1995;
Bennetto et al. 1996).
Weak central coherence (Happe, 1995)
Central coherence is the
ability to see the “big picture” rather the details. Central coherence theory
explains the non-social features of autism. According to the theory, people
with autism tend to focus on details, rather than the global aspects of an
entity. However, Hill and Frith [12]
argue that the main problem of the central coherence theory of autism, and its
variants, is a lack of plausible neuroanatomical mechanisms in which the nature
of the abnormal activation could illuminate the observed behavioural features.
Clearly, a great deal of neuroanatomical work must be done to investigate this.
Deficiencies [10], [11]
Deficiencies are observed in attention, spoken language, social and
emotional expression, play, sensory process and cognitive skills. However,
scientists also refer to some special skills, such as exceptional ability of
memorization, high ability in maths, hyperlexia and skillfulness in puzzles and
complicated games, which people with autism have.
-
Attention
¨ eye-to-eye gaze
¨ distraction
¨
persistent
preoccupation with part of objects
¨ anxiety
-
Spoken
Language
¨ echolalia
¨ disturbed articulation
¨
speech
and language absence or delays
¨ inappropriate laughing and giggling
¨ repeated speech
An aspect of language that tends to be disturbed in autistic people has
to do with knowing how to use language appropriately and in context. That
includes knowing how to hold a conversation, thinking about what the other
person in a conversation understands and believes, and tuning in to the meta -
linguistic signals of the other person, such as facial expression, tone of
voice and body language
-
Social
and Emotional Expression
¨
avoidance
of physical contact (e.g. no seeking of cuddling)
¨ avoidance of social interaction
¨ indifference towards peers
¨
indifference
towards humans in general
¨ lack of empathy
Phil Schwarz, a software developer from
The "intense world"
theory [15], which has been put forth by Henry and Kamila Markram of the Swiss
Federal Institute of Technology in
-
Play
¨ peculiar/ odd play
¨ absence of symbolic play
¨ absence of interactive play
¨
excessive
preoccupation with certain games
-
Sensory
Process
¨
peculiar
processing of visual stimuli (e.g. fixed stare)
¨
indifference
or excessive response to auditory stimuli (e.g. they do not respond to
excessive noise, but they close their ears with the sound of an electric brush
¨
indifference
or excessive response to tactile stimuli (e.g. they do not respond to painful
stimuli, but they cannot stand tender caresses, etc..
-
Cognitive
Skills
¨ retardation
¨ inconsistent learning
¨
stereotypes (in visual stimuli, smell, speech,
taste, move, routines or rituals)
Comorbidities
Autism might coexist with many other conditions. For example, 30% of people
with autism develop clinically apparent seizures (imbalances in cortical
circuits) (Lord and
Spence, 2006).
Furthermore, autism may coexist with neurofibromatosis, congenital rubella, hydrocephalus,
ambulation, fetal alcohol syndrome and fragile X syndrome. It is estimated that at least 24% of cases of autism are
potentially associated with other syndromes, to infective, metabolic or genetic
pathologies, and to anatomical or functional alterations [5]. Studies to date
report that somewhere between 2% (Collacott et al. 1992, cited in Hepburn, 2007),
5% (Ghaziuddin et al. 1992, cited in Hepburn, 2007), 7% (Kent et al. 1999,
cited in Hepburn, 2007) and 10% (Paly & Hurley 2002, cited in Hepburn, 2007)
of individuals with Down syndrome meet the criteria for autism or autism
spectrum disorders [17]. Although there is a substantial amount of
research to support high rates of ID (intellectual disability) in autism (70-80%),
this finding has been disputed in an extensive review by Edelson [14].
Currently, eating and feeding disorders
have been associated with ASD. Pica is defined as the persistent eating of
nonnutritive substances for longer than one month that is inappropriate for
one’s developmental level (APA, 2000). Lo Vullo [14] argues that the rates of
Pica may be higher in ASD than in other developmental disabilities. The
identification and treatment of Pica is crucial because this behavior can lead
to severe medical complications, including intestinal parasites, infections,
surgical complications from removing objects, toxicity, and death [14]. Rumination
Disorder is defined as the repeated regurgitation and rechewing of food, with a
pattern that occurs for longer than one month that is not attributable to a
general medical condition, anorexia, or bulimia (APA, 2000). The comorbidity of
rumination and ASD has not been supported. However, 6-10% of institutionalized
individuals who have severe or profound ID ruminate on a regular basis (Fredericks,
Carr, & Williams, 1998).
Assessment
from the view of Speech and Language Clinical Practice – Diagnostic criteria
However genetic contribution to
autism has been supported, the diagnosis of this condition looks to behavioral
characteristics. According to ICD-10
– DSM-IV [16] the symptom criteria for diagnosing ASD, are based on a
triad of impairments:
Social: impaired, deviant and delayed or atypical
social development, especially interpersonal development.
Language communication: impaired and deviant language and
communication, verbal and non-verbal -impairment in pragmatic aspects of
language.
Thought and Behavior: rigidity of thought and behaviour
and impoverished social imagination -ritualistic behaviour, reliance on
routines, impairment of imaginative play.
DSM-IV criteria for autistic and Asperger's disorders were applied to
157 children with clinical diagnoses of Autism
or Asperger's disorder [9]. All children met the DSM-IV criteria for
autistic disorder and none met criteria for Asperger's disorder, including
those with normal intelligence and absence of early speech delay. The reason
for this was that all children had social
impairment and restricted and repetitive behavior and
interests (required DSM-IV symptoms for both autistic and Asperger's disorders)
and all had a DSM-IV communication
impairment (which then qualified them for a diagnosis of autistic
disorder and not Asperger's disorder). According
to the DSM-IV, children with Asperger's disorder do not have significant
cognitive or speech delays, whereas children with autistic disorder may or may not.
Results suggest that early
speech delay may be irrelevant to later functioning in children who have
normal intelligence and clinical diagnoses of autism or Asperger syndrome and
that speech delay as a DSM-IV distinction between Asperger's disorder and
autism may not be justified.
Despite the availability of
classification systems such as the DSM-IV-TR and the ICD-10, the diagnosis of
an ASD can provide a clinician with “unique challenges” (Lord, 1997). SLTs
(speech and language therapists) firstly seek information through history
taking procedures. Obtaining
an accurate history taking is the critical first step in determining the
aetiology of a patient’s problem. Furthermore, scientists very often make
diagnosis based on histories alone. During history taking, speech and language
therapists ask specific questions, either of the
patient or of other people who know the person and can give suitable
information.
History taking
may be a very comprehensive procedure. In this case several domains are
examined. More specifically, history taking is divided into a number of
categories. That is, parental and birth history [(e.g. Mother’s general
health during pregnancy (illnesses, accidents, medications, etc.), unusual conditions
that may have affected the pregnancy or birth],
medical history of the child (i.e. list of any
illnesses or medical conditions suffered by the child), developmental history [(i.e.
the recorded developmental progress of a child (ages birth to 18 years) in such
skills as sitting, walking or talking] and educational history [1]. Last but
not least social history provides SLTs with quite crucial information regarding
the child. In this case, much of the information may be obtained by a
social worker who works with the SLT. Healthcare social workers are invaluable
resources. Generally, using a team approach can greatly assist in the
acquisition of needed information and in the further care of the patient and
family.
The CHecklist for Autism in Toddlers (CHAT) is a
screening instrument that was devised to test the prediction that those
children not exhibiting joint attention and pretend play by the age of 18
months will be at risk for receiving a later diagnosis of autism [2]. Many SLTs
use the first part (i.e. questions directed to parents) of the invaluable Check
list for Autism in Toddlers (Baron-Cohen et al., 1996).
Clinical Observation/Assessment
(Informal – Formal assessment)
The initial approach to the assessment of
these disorders was unsystematic and unreliable, and as a consequence,
structured assessment instruments were developed [14]. Formal assessment supplements the process of clinical observation. There
are many instruments used -by psychologists, SLTs, psychiatrists and others- in
the identification of ASD in children and adults. Some of the most commonly
used are listed below [7].
¨
¨ Childhood Autism Rating Scale, (1988)
¨ Aberrant Behavior Checklist (ABC), (1980)
¨
Autism Diagnostic Interview-Revised (ADI-R), (1994)
¨
Autism Diagnostic Observation Schedule -Generic
(ADOS-G) (revised and
combined version of two previously used instruments, the ADOS (Lord, Rutter,
Goode, & Heemsbergen, 1989) and the Pre-Linguistic ADOS (PL-ADOS; DiLavore,
Lord, & Rutter, 1995)
Checklists
¨ Atwood Asperger’s Syndrome Checklist
¨
ASPERGER
SYNDROME CHECKLIST OF POSSIBLE BEHAVIORS (Nancy Dalrymple, PhD and Lisa Ruble,
PhD.
¨
The
Autism Checklist [Glynis Hannell, BA (Hons), Msc Registered Psychologist]
¨
The
Asperger Syndrome Checklist [Glynis Hannell, BA (Hons), Msc Registered
Psychologist]
Informal assessment:
Assessments cannot be rushed. Two or more sessions might be needed in
order to obtain sufficient evidence. The environment where the assessment takes
place is very crucial for the diagnostic procedure. The assessment in an
unfamiliar place may not allow the child to express its potential. Apart from
the official department, thorough assessment means assessment in school, house
and elsewhere. During the assessment specialists should bear in mind the
individual profiling (strengths and difficulties vary from person to person). Comprehensive
evaluation of communication, speech and language skills consists of examination
of many aspects of language. That is clinical evaluation of language
fundamentals (receptive/ expressive language subtests): semantics, morphology
and syntax, auditory memory etc. Moreover, standardized expressive vocabulary
tests are used to define and distinguish between language delay and language
disorder. There are other parameters which are included in thorough
assessments. That is the examination of sensory-motor profile (orofacial examination),
speech examination (phonetic-phonemic level), play assessment (symbolic play,
interactive play), emotion perception tests, pragmatics profile, theory of mind
stories - Sally-Anne test - and tests of problem solving (making inferences,
predicting, determining causes, sequencing, problem solving).
Discussion
Nowadays in
References
[1] Anonymous: A national clinical
guideline. Assessment, diagnosis and clinical interventions for children and
young people with autism spectrum disorders. 2007;
[2] Baron-Cohen
S et al., (2000): The early
identification of autism: the Checklist for Autism in Toddlers (CHAT). Journal of the Royal Society of Medicine.
2000; 93:
1-25
[3] Baron-Cohen S: Autism: The
Empathizing–Systemizing (E-S) Theory. Annals
of the
[4] Baron-Cohen S: Theory of mind in
normal development and autism, Prisme,
2001; 34: 174-183
[5]Celani G.
Comorbidity between Autistic Syndrome and Biological Pathologies: Which
Implications for the Understanding of the Etiology? Journal of Developmental and Physical Disabilities. 2003; 15(2):141-154
[6] Chew K: Extremes and Empathy.
2002
Available from: URL: http://autism.change.org/blog/view/extremes_and_empathy
[7] Connor M: Children on the
Autistic Spectrum: Guidelines for mainstream practice. 1999
Available from: URL: http://www.mugsy.org/connor2.htm
[8] Dahlgren S.O. et al: Theory of
Mind in Non-Retarded Children with Autism and Asperger's Syndrome. A Research
Note. Journal of Child Psychology and Psychiatry. 2006; 37(6): 759-763
[9] Dickerson S, Calhoun L,
& Crites D. L: Does DSM-IV Asperger's Disorder Exist? Journal of Abnormal Child Psychology. 2001;
29(3): 263-271
[10] Frith U: Autism. Translated form English, 1999,
[11] Gena Α: Autism
and Pervasive Developmental Disorders. 2002,
[12] Hill E, and Frith U: Understanding
autism: insights from mind and brain. The
Royal Society. 2010; 281-289
[13] Hobson R.P. et al: What’s in a face? The case of
autism. British journal of Psychology. 1988; 79(4): 441-453
[14]
LoVullo S V: Thesis: Comorbid psychopathology in individuals with autism
spectrum disorders and intellectual disabilities, 2009: 1-63
[15] Markram H, Rinaldi T, Markram K:
The Intense World Syndrome – an alternative hypothesis for autism. Frontiers in Neuroscience, 2007;
1(1): 77-96
[16] Pasxalidis ed: Diagnostic and Statistical Manual of Mental
Disorders DSM-IV-TR. American Psychiatric Association, 2006,
[17] Hepburn S.,
Philofsky A, Deborah J. Fidler D. J,
Autism symptoms in toddlers with Down syndrome: a descriptive study.
Journal of Applied
Research in Intellectual Disabilities 2008; 21: 48–57
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