Autism is a complex developmental disorder. The symptoms of autism typically appear in the first three years of life. It is a neurological disorder that impacts the development of language and communication skills as well as social interaction and relatedness. In addition, individuals with autism may demonstrate repetitive stereotyped behaviors, unusual responses to sensory stimulation, restricted interests and a resistance to change.
Autism is one of five disorders that falls under the category of Pervasive Developmental Disorders (PDD) which is a set of disorders characterized by severe and pervasive impairment across several areas. Asperger’s disorder, Childhood disintegrative disorder, Pervasive developmental disorder-not otherwise specified (PDD-NOS) and Rett’s disorder are the remaining four PDDs. Typically, Autism, Asperger’s disorder and PDD-NOS are referred to as the Autism Spectrum Disorders.
Recent research has revealed that symptoms of autism may be present as early as 6-12 months of age. The earliest symptoms include a pronounced lack of social orienting, failure to respond to name, and lack of a social smile. By the second year of development, there may be limited eye contact, odd or unusual repetitive use of objects or toys, delayed or absent speech development as well as a preference to play along.
Autism affects boys 4-5 more frequently than girls. There is no known cause of autism. It is believed to have a strong genetic component. In a family with one autistic child, the chance of having another child with autism is about 1 in 20, much higher than in the normal population.
Asperger’s disorder (AD) affects social development. Individuals with AD typically demonstrate significant challenges in social interactions as well as restrictive and repetitive behaviors and interests. It differs from autism in that language and cognition are not significantly affected. Although AD is thought to be present in early development, many individuals are not identified or diagnosed until they enter school, or even later. A number of individuals are not diagnosed until they are adults. As with autism, AD also has a higher incidence of co-morbid conditions, particularly anxiety, OCD, and in some cases, depression. In addition, AD also affects boys far more frequently than girls. The most significant challenge faced by individuals with AD lies in the ability to recognize or understand social cues and situations. In many cases, despite good language and cognition, individuals with AD are socially isolated and have a difficult time with employment.
PDD-NOS is sometimes referred to as atypical autism. Individuals who receive a diagnosis of PDD-NOS have some of the symptoms of autism, but do not sufficiently meet all the criteria. Because of the lack of specificity of this diagnosis, it has been difficult to conduct any research and clearly understand its course of development. It has been speculated that this group demonstrates fewer deficits as adults when compared with the more classic autism group.
Childhood disintegrative disorder (also referred to as Heller’s disease) develops between the ages of two and ten. These children typically develop normally until two or three years of age and then development deteriorates rapidly. Deterioration or regression occurs across all areas of development including speech and language, play skills, bowel and bladder control and socialization. In many cases, the child looks very much like a child with more classic autism, following the period of regression. The difference lies in the age of onset.
Rett’s syndrome is a neurological disorder that affects girls almost exclusively. Rett’s has been described as having four stages. In the first stage, the child appears to be developing normally. Typically, at around 18 months, development seems to slow down or even stop. While phase two is marked by this slowing of development, in phase three, there is a loss of skills. Phase three occurs between 12 months and three years of age. As with CDD, this loss of skills is pervasive, across language, social skills and motor development. Phase four is the learning phase. Children with Rett’s do learn skills, but do so at a slow rate. Rett’s is also accompanied by more physical problems than the other PDDs. Individuals with Rett’s have high rates of seizure disorders, difficulty chewing and swallowing, motor problems, small head circumference, problems with constipation as well as impaired circulation with legs and feet.
Estimates of the prevalence of autism continue to vary widely. While many can not agree on the actual number of children being identified with autism, all agree that the number has risen dramatically over the past 15 years. The most agreed upon numbers appear to indicate that the prevalence rate is about 1 in 500 children, and this number drops to approximately 1 in 100 when including Asperger’s disorder and PDD-NOS. It is clear that part of this increase can be accounted for by expanded definitions of ASD as well as improved diagnostic tools and better skilled diagnosticians. It is not yet clear, however, if these can explain the entire increase. Some researchers believe that an as yet unidentified contributing environmental risk factor cannot be ruled out.
Although there is no known cure for autism, there have been significant advances in the education and treatment of individuals with autism. To date, the use of applied behavior analysis within a comprehensive education program has shown the most positive results. Intervention that begins early (at diagnosis) and is intensive (20-40 hours per week) is widely agreed to be critical to promote best outcomes. Some believe that ABA is no longer useful beyond age six. This is clearly not true. There are over 500 articles published that document the efficacy of intervention for older children and adults using applied behavior analysis. The research indicates that programs working with older children and adults should focus on promoting independence, enhancing speech, language and communication, as well as the reduction of challenging behaviors. For individuals with AS and HFA, it is critical to continue to address social skills development.
What Is Applied Behavior Analysis?
Applied Behavior Analysis is the science of human behavior. The best definition available is still the one written about in 1968 by Baer, Wolf, & Risley:
“Applied Behavior Analysis is the process of systematically applying interventions based upon the principles of learning theory to improve socially significant behaviors to a meaningful degree, and to demonstrate that the interventions employed are responsible for the improvement in behavior“
There are hundreds of research articles demonstrating the efficacy of applied behavior analysis as an intervention for individuals with autism. These studies range from group design outcome studies to single subject studies supporting the use of one specific intervention or technique.
Specifically, Applied Behavior Analysis involves the principles of learning theory. That is, the contingent use of reinforcement and other important principles to increase behaviors, generalize learned behaviors or reduce undesirable behaviors is fundamental to ABA.
The second key feature in Baer, Wolf and Risley’s definition involves to notion of demonstrating efficacy. It is essential that individuals using ABA evaluate the interventions to determine their efficacy and make modifications as needed to insure consistent and ongoing progress.
The most important component of ABA involves the notion of “socially significant behaviors to a meaningful degree”. It is imperative that programs and interventions focus on outcomes for the learners that will have socially significant consequences and that this change is to a meaningful degree.
There are many different teaching strategies that are used under the umbrella of Applied Behavior Analysis. These include shaping and chaining behaviors. In addition, it includes specific teaching strategies such as discrete trial instruction, pivotal response training, incidental teaching, fluency based instruction and many more. Each of these instructional techniques has a rich empirical support base.
Baer, D.M., Wolf, M.M., & Risley, T.R. (1968). Some current dimensions of applied behavior analyis.
Journal of Applied Behavior Analysis. 1, 91-97.
What is Stereotypy?
What is stereotypy?
Stereotypy is defined in the research literature as “contextually inappropriate and repetitive operant motor movements maintained by automatic reinforcement”. In lay terms we are talking about behaviors that the person is able to control, that are repetitive, and that serve no functional purpose. Another important feature is that the person does stereotypy because he or she enjoys the sensation or stimulation they get when they do the stereotypy. This is why many people call stereotypy “stimming”. In fact, the terms stimming and stereotypy are almost interchangeable in the autism community.
What does stereotypy look like?
Stereotypy comes in many forms. The most common forms are hand flapping, shaking objects and repeating vocal sounds. However there are many more forms of stereotypy and these include opening and closing the mouth, facial grimacing, head tilting, head shaking, shoulder shrugging, body tensing, stamping feet, twirling objects, spinning, ear covering, staring at objects, side looking and vocal scripting.
Why do people with autism do stereotypy?
A very simple answer to that question is that people with autism do stereotypy just because they like doing it. But that answer always leaves people wondering why people with autism like doing stereotypy. Unfortunately, there is no simple explanation for why people with autism like doing stereotypy. My experience is that the people with autism who do a lot of stereotypy tend to lack appropriate leisure skills. In other words they do stereotypy because they are not able to entertain themselves in any other way. Additionally, stereotypy tends to interfere with learning. So there is this kind of cycle where stereotypy happens because the person does not have leisure skills, and the stereotypy prevents the person from learning new skills, which further contributes to the person not having leisure skills.
Should we treat stereotypy?
Absolutely! It is very important to make stereotypy go away, especially in younger people with autism. There are several reasons to eliminate stereotypy in people with autism. First, stereotypy interferes with skill acquisition. This means people who do a lot of stereotypy tend to make slower progress at school. People who engage in stereotypy often experience difficulties in the community and it is more challenging for them to interact with their peers. Another big reason to target stereotypy is that people who engage in a lot of stereotypy are at a much greater risk of developing other, more severe behaviors like self-injury and aggression. Stereotypy is also associated with higher levels of parenting stress and parents often rate stereotypy among the most difficult aspects of autism to deal with.
What are some ways to treat stereotypy?
There are several viable treatment procedures for stereotypy that have the support of scientific research. All of these interventions come from the field of Applied Behavior Analysis (ABA), and are considered evidence-based practices because their effects have been proven and reported in scientific studies. Generally speaking parents and clinicians should use only evidence-based practices when attempting to treat stereotypy and other maladaptive behaviors associated with autism. Additionally, these procedures are very technical in nature and require assessment and supervision from a skilled clinician, ideally a Board Certified Behavior Analyst (BCBA), in order to be properly carried out. These procedures are unlikely to work without the support of a skilled clinician.
Here is a list of procedures along with a brief description of each:
Differential Reinforcement of Other behavior (DRO): With DRO the person receives a preferred item or activity (i.e., a reinforcer) for intervals of not engaging in stereotypy. Initially the interval is very short so the person can easily receive the reinforcer, but the duration of the interval is systematically expanded based on the person’s progress.
Sensory Extinction: With sensory extinction the person is prevented from receiving the sensory reinforcer that is maintaining the stereotypy. This may involve blocking the behavior from occurring.
Environmental Enrichment: This is a procedure that involves providing the person with some other form of stimulation so that they no longer need the stimulation they receive from doing the stereotypy.
Leisure Skills Training: Leisure skills training is a long-term solution for stereotypy. The idea is to teach the person to do some appropriate behaviors instead of doing the stereotypy. Remember stereotypy is usually happening because the person has no other way of entertaining himself or herself. So by teaching leisure skills the person learns a new way of entertaining himself or herself. Puzzles, peg boards, building blocks, coloring, lacing cards, mosaic designs, picture activity schedules and even computer and video games are great skills to start with.
Article by Geoff DeBery, M.A., BCBA