The child being evaluated is given just one module depending on his or her expressive language level and chronological age. The interview measures behavior in the areas of social interaction, communication and language, and patterns of behaviour. It involves the use of carefully chosen rewards and consequences to help shape a child's behaviour. These can include parents, carers, siblings, wider family, friends and school, etc.
Understanding the ways in which the relationships connect can be helpful for all those involved. Family therapy usually involves children being seen with their parents together with their brothers and sisters. Mellow parenting Once a week parents meet to explore and understand their own past and current difficulties and how they may impact on their parenting. The group allows parents to feel supported by other parents who share their experience, and helps to make them feel less isolated.
Music therapy The music therapist works at the Croft for two days a week. Individual sessions, group sessions and sessions for children and their families are offered as part of this service. Music therapy diagnostic assessments can assist the team in assessing children or families. Short-term music therapy treatment may be able to address some of the difficulties a child or a family may be experiencing. Story stems In this technique,children are presented with a range of different family scenarios as the beginnings of a story, using doll and animal figures as well as language.
A recent approach to social difficulties is a training package designed to improve the ability to mind-read.
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It seems to exist a direct relationship between time spent in a classroom, working on an academic subject, and the improvement achieved in that subject. A common question has been whether an autistic child should attend a special school for autistic children specialized in broad learning difficulties or being integrated into the mainstream school.
So far there is no final answer to this question as there is no well-controlled comparative study concerning the levels of integration in these systems. It seems that each case should be individually treated, focusing on the child's needs and strengths. It is important to bear in mind the advantages of being exposed to non-handicapped children and learning from them by imitation but not forgetting that they will be at risk for bulling by other children.
As mentioned before, studies about teaching programmes such as TEACCH show the importance of environmental organization, the use of visual clues and the work based on the child's previous skills rather then trying to overcome the main deficits of autism. Kanner, in , provided one of the first descriptions of the benefits of this sort of work in the case of Donald.
She noted that the teacher used to deal properly with his bizarre behavior and the farmers have taken advantage of his obsessional behaviors making them much more functional, for example, his obsession for numbers was used in activites where measures were needed in the farm area. There is evidence that early educational provision, since 2 to 4 years, combined with the integration of all professionals is the most effective therapeutic approach.
These strategies help to minimize or avoid subsequent behavioral problems as the children quickly learn that their behaviors may serve as a mean to control the environment. Another approach that has some empirical base is the Lovaas' method. Different developmental areas such as language, cognitive aspects and social behavior are target.
One of its limitations is that it imposes some restrictions to the families such as determining the hours when family members must be available and committed to the programmes, perhaps giving up planes such as a pregnancy, new post at job, etc. Traditional behavior therapy such as the ABA approach to the analysis of behavior also appears to be helpful. The main assumption is that the behavior can be understood by the identification of the antecedents and consequences of a certain behavior.
However, attention has been called to the fact that it is very difficult to take into account the behavior as perceived by the child, making possible to explain a certain behavior by other that preceded it or not. Decreasing behaviors that interfere with learning and access to opportunities for normal experiences.
Attention has been called to the "function" of challenging behaviors, that is, the underlying causes of behavioral disturbances e. There are authors who point out that intervention techniques should focus on the improvement of developmental areas, mainly social skills and language, rather than on the elimination of problems.
The knowledge that challenging behaviors are a way to communicate also allows people to respond better to these behaviors because they know that they were elicited due to poor communication and are not deliberate acts of aggression. There are approaches that can help to reduce these behaviors by helping the child to use alternative means of communication. In fact, most studies investigating the efficacy of these approaches show decreasing of these behaviors when the appropriated technique is used, which is, the identification of the underlying function of the behaviors.
However, it should be noted that most of these are studies using small samples or single-case design, multiple baseline or Applied Behavioral Analysis ABA type design.
Very few are randomized treatment trials which would allow a wider and more accurate interpretation of the results. One limitation of these approaches is that idiosyncratic or multifunction causes of these behaviors cannot always be identified. There are authors that emphasize how important it is not to encourage or tolerate behaviors that will later be perceived by others as inappropriate. In this case, problems arise not due to the nature of the behavior but because of changes in other people's attitudes.
Some types of obsessive compulsive behavior e. Of course it does not mean that these activities should be forbidden. They should not be too much encouraged as they may escalate and interfere in the learning process if not brought under control. Without careful planning, children may replace rituals and obsession with behaviors that are even more disruptive. It is important to highlight that the modification of challenging behaviors shall be made gradually with the reduction of anxiety and distress being the main goal.
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There are some helpful guidelines, which include the establishment of clear and consistent rules when the behavior is not allowed or permitted , graduation of change; identification of underlying functions such as anxiety or uncertainty; environmental modifications e. Regarding social behavior, in children who are more severely handicapped, inappropriate behaviors such as screaming, undressing or masturbating in public may be a great source of concern.
On the other hand, children less handicapped have, as the source of concern, difficulties in empathy, social understanding and reciprocal interactions that seem to be the core deficits in autism. This social impairment can be better explained by deficits, in theory of mind, that are, the ability to understand other people's beliefs, thoughts or feelings. It seems that social skills training is more effective when conducted in a particular situation, as each situation demands a different social response.
Isolating social skills groups tend to be a more limited procedure due to the child's difficulties with generalization of the acquired skills. Learning how to interact with children of the same age is a demanding task for autistic children.
Pervasive Developmental Disorders
There have been some studies with intervention designs that range from constant input of teachers to free-play groups that involve children with typical development. Again, with the different designed interventions although there were improvements in the frequency of interaction it was difficult to maintain peers' co-operation for longer periods of time. Offering opportunities e. There is evidence that autism has some impact over the family and that the burden of care falls largely upon the mothers. One study compared the stress profiles of mothers and fathers of children with autism.
Another study showed that mothers of children with autism also showed more depression than mothers of Down Syndrome children suggesting that the burden of caring and the nature of child's handicap play a part in maternal depression. A study investigating the role of perceived parenting stress and parental depression on marital intimacy between parents of handicapped children showed a similar result.
It was demonstrated that parents are most stressed by delays in getting a diagnosis, 2 by disabilities associated with autism itself e. One study 33 showed that mothers of the autistic children have higher scores in most of the General Health Questionaire GHQ dimensions, compared to the mothers of children with learning difficulties and typically developing children. These concerns gave place to real demands as developmental problems were identified by the child's birth for the learning disabilities group and for the autistic group within the first two years.
The impact of the stressor on the family may be increased if there is accumulation of preexisting or simultaneous demands on the family unit.
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In addition, in that study, the majority of mothers of the clinical groups did not work a condition that may increase the burden and social isolation. In fact, some mothers gave up their careers to look after the child. Sleep problems were identified in the children of both clinical groups such as difficulties to go to sleep and frequent waking and restless. It was called attention for the role of family routines, in particular bedtime routines for children to prevent parental stress and lack of couple intimacy. Social support is an important resource to the family and has been viewed as one of the key stress buffering factors in families under stress.
The information exchanged at the interpersonal level provides emotional support, esteem support and feelings of belonging to a network of communication with mutual understanding. The authors claim that professionals working with these families can help them to assess both stresses and resources in order to solve problems. Families can be helped to be more resilient in the face of change by restructuring roles, rules, patterns of interaction, boundaries and outside relationships with the community.
Appraisal may also play a part as it refers to the families' set of beliefs and assumptions about their relationship to each other and also about the community and systems beyond their boundaries. In that study, mothers also reported how helpful it was having support, at home, about the management of the child's behavioral problems, and in particular those associated with everyday tasks.
Even within a family, each member may have different views and expectation about the child and their needs. It was pointed out that is not enough to say to parents what they should do but to show them how to do. Teaching management techniques and providing information about the condition is as important as focusing on emotional aspects. Attention was also called about the importance of advising parents about the advantages and disadvantages regarding different treatments.
Consequently, their value remains uncertain. Diagnosis during the pre-schools years is still very rare, despite the claims that early intervention is the best procedure for child's development. The most common situation is that the worries of parents and professionals lie on child's speech delay rather then on the social aspects of behavior.
Accurate diagnosis is not an easy task for professional as there can be problems in distinguishing between children with autism and non-verbal children with learning disabilities or language impairment. However, by the age of 3 years, children tend to meet autism diagnostic criteria on a variety of diagnostic measures. Unnecessary delays in diagnosis have important practical implications as the development of effective although simple communication strategies at an early stage of life help to prevent disruptive behavior.
It was mentioned before that the best predictor of the subsequent development are both the level of communication and cognitive abilities developed during the pre-school years.
BMJ Best Practice
Practical guidelines for health professionals in the community to reach this goal have been the focus of some studies. When facing a diagnosis of pervasive developmental disorder, all families wonder what type of psychoeducational intervention is the most effective. The answer is not so straightforward as it appears, despite the large amount of treatments that have been advertised.
By reviewing the current literature on the different interventions that have been used in the treatment of autism we concluded that few are empirically based. Although some sort of improvement can be demonstrated in different studies, the results should be interpreted with caution as well-controlled studies are very rare. Apparently there are no single approaches that are totally effective for all children, along the different stages of life. That is, a specific intervention that may work well in a certain period of time e.
This occurs in part because families change their expectation and values regarding their children's treatment according to the child's development and the family context. On the other hand, a point of consensus in the literature is the importance of early identification of autism and early intervention and their relationship with subsequent development.
Finally, another issue to bear in mind is the need to focus on the whole family rather then only on the individual with pervasive developmental disorder. Rutter M, Schopler E. Classification of pervasive developmental disorders: some concepts and practical considerations. J Autism Dev Disord. Howlin P, Moore A. Diagnosis in autism: a survey of over parents. Autism Intnl J Res Pract. Gillberg C. Do children with autism have March birthdays? Acta Psiquiatr Scand. Howlin P. Prognosis in autism: do specialist treatments affect outcome?
Eur Child Adolesc Psychiatry. Venter A. A follow-up study of high-functioning autistic children. J Child Psychol Psychiatry. Aman MG. Treatment planning for patients with autism spectrum disorders. J Clin Psychiatry.
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Lord C, Rutter M. Autism and pervasive developmental disorders. Child and adolescent psychiatry: modern approaches. Oxford, UK: Blackwell Publishing; Bondy A, Frost L. Educational approaches in preschool: behaviour techniques in a public school setting. Learning and cognition in autism. New York: Plenum Press; Quill K. Instructional considerations for young children with autism: the rationale for visually cued instruction. Changing approaches to communication training with autistic children. Br J Disord Commun. The understanding and use of interpersonal gesture by autistic children and Down's syndrome children.
Practitioner review: psychological and educational treatments for autism. Multiple Method validation study of facilitated communication: II Individual differences and subgroup results. Green G. The quality of the evidence. In: Shane HC. Facilitated communication: the clinical and social phenomenon. Psychoeducational Profile Revised.
Leon V, Bosa C. Autism in press. Teaching children with autism to mind read: a practical guide for teachers and parents.