Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5541_Библиотеки_им_академика_М_И_Перельмана.pdf
124 Chapter 7 Autism Spectrum Disorder
Protective factors
Alternative
Cumulative
Cascading
Figure 7.6 Multiple pathways may lead to
autism spectrum disorder
Routes
Autism
symptoms
Risk factors
Source: Gliga, Jones, Bedford, Charman, & Johnson (2014). From early
markers to neuro-developmental mechanisms of autism.
symptoms
there protective factors that may be identified in infancy or
toddlerhood that might explain why the majority of highrisk infants do not go on to meet criteria for ASD, even
though they have many of the same indices (from genetics to
phenotypes) as infants who do go on to have ASD” (TagerFlusberg, 2014, p. 657). The most useful etiological models
will address all of these developmental pathways.
Effects
Autism
symptoms
Compounded
Environment
development
Genes and Heredity
Most children with autism are born to parents without
autism. Given high heritability and familial clustering, this
occurs because the genetic variants carried by unaffected
parents are passed to their children (Constantino et al., 2021).
Hundreds of genes have been identified that contribute
to ASD risk (Lord et al., 2018; Thapar & Rutter, 2021).
Polygenic models of autism focus on the accumulating and
cascading effects of multiple genes with a mix of common
variants, rare variants, and de novo mutations. Common
variants contribute most of the risk, each with small impact.
Rare variants contribute less overall risk, but with larger
impact. De novo mutations appear to be more frequent with
older parents, especially older fathers (Mandy & Lai, 2019).
Genetic models also help clarify the overlap between ASD
and other neurodevelopmental disorders such as intellectual
disability and ADHD by identifying genetic mechanisms
that disrupt multiple brain processes (Constantino et al.,
2021; Thapar & Rutter, 2021).
range from 65%–93% (Bai et al., 2019; Bralten et al., 2018;
Lord et al., 2018; Thapar & Rutter, 2021). Despite high
heritability, however, there is significant variability in the
clinical presentations of MZ twins who are both diagnosed
Heritability estimates across studies and across countries
Effects
Autism
during
with ASD. This suggests a possible role for non-shared
environmental factors and epigenetic processes (Castelbaum
et al., 2020; Thapar & Rutter, 2021).
Baby sibling research, as well as research on the broad
autism phenotype, supports genetic and dimensional
explanations. Approximately one in five siblings of older
siblings diagnosed with ASD are also diagnosed with ASD
(Lord et al., 2018; Vivanti & Messinger, 2021). There is
also compelling evidence of overlap between the genetics
of ASD, autistic traits, and the broad autism phenotype
(Klin et al., 2020). Studies of parents of children with ASD
reveal a wide range of prevalence estimates for the broad
autism phenotype (dependent on research designs), from
3% to 80%. The broad autism phenotype is more frequently
observed in fathers (Rubenstein & Chawla, 2018).
Gene-by-environment-by-time processes and interactions
such as active and evocative gene-environment correlations
provide additional information about the development of
ASD. Gene-by-environment-by-time explanations must
account for the ongoing influence of genes over the lifespan,
gene-brain-behavior connections, and the influence of
environmental factors at various developmental periods
(Klin et al., 2020; Thapar & Rutter, 2021).
Physiological Factors
Physiological factors influencing brain development, brain
struct ure, brain organiz ation, and brain chemistr y help explain
the multiple impairments observed in ASD. At the macrolevel, there is abundant evidence that brain development
is atypical. The growth dysregulation hypothesis proposes
that the usual well-controlled process of brain growth and
organization goes awry, leading to the clinical symptoms of
autism (Courchesne et al., 2011; Courchesne & Pierce, 2005).
It appears that early brain overgrowth in both gray and white
matter in the frontal and temporal regions during infancy and
early childhood is followed by an accelerated rate of decline
in size and possible further deterioration from adolescence
forward (Courchesne et al., 2011; Lord et al., 2018).
At the micro-level, investigations of neuronal and synaptic
growth and pruning, along with methylation, also reveal
atypical processes (Johnson et al., 2015). The over-pruning
hypothesis describes “overly aggressive synaptic pruning” in
the sensory and/or motor regions (Thomas et al., 2016).
Brain chemistry research examines protein networks and the
balance between inhibitory and excitatory neurotransmitters,
with a focus on atypical signal-to-noise ratios in neural
processing and poor-quality synaptic processing (Bralten
et al., 2018; Gliga et al., 2014; Johnson et al., 2015).
Atypical structure and function of multiple brain
regions associated with joint attention, face processing, and
the social reward system have been identified (Clements
et al., 2018; Mundy, 2018). In addition, dysfunction in the
mirror neuron system has also been investigated (Oberman
& Ramachandran, 2015). Mirror neurons are located in
the cortical motor system and respond to the observation
of others’ motor acts. Mirror neuron activity is believed to
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Etiology 125
underlie the understanding of motor acts done by others as
well as the intentions behind the actions. In children with
ASD, dysfunction in the mirror neuron system may help
explain some of the difficulties in social cognition that are a
core component of the disorder.
Although there is compelling data about the roles of
specific brain regions and processes in ASD, there has been
a major shift toward brain-wide explanations. These wholebrain approaches examine atypical connectivity across
brain regions, with particular attention paid to circuits
connecting social, cognitive, and emotional processes
(Constantino et al., 2021; Ecker et al., 2022; Szatmari
et al., 2016). Understanding both underconnectivity
and overconnectivity is complicated and must take into
account patterns of atypical connectivity over development.
Atypical brain structure, function, and connectivity are also
observed in individuals with the broad autism phenotype
(Thapar & Rutter, 2021)
Johnson et al. (2015) describe several key characteristics
of brain organization and function: built-in redundancy;
hierarchical organization, with the prefrontal cortex
“uniquely placed to influence other brain regions” (p. 428);
niche construction, with an emphasis on individuals’ active
construction of their environments; and adjustment of
developmental rate. For children with autism, the hypothesis
is that “the attentional style characteristic of autism (i.e.,
overly focal, biased to simple repetitive events, and highly
alert) is the result of an atypical brain adapting to the pace
and quantity of information flow” (Johnson et al., 2015, p.
435). Redundancy, however, means that there may be ways
to intervene so that individuals can compensate for atypical
network structure or function.
Overall, atypical brain-behavior processes influence
a range of ASD patterns and pathways. Early disruptions
of molecular, cell, and brain circuitry that interact with
environmental factors over time provide strong evidence for
“a brain-behavior tight system of interdependence,” with
“brain-mediated, bi-directional, and iterative relationships
between a child and their social and physical environments”
(Klin et al., 2020, p. 1180). Additional data supporting the
impact of brain-behavior processes in the development of
ASD are provided by studies of medical conditions associated
with adverse consequences on early brain development.
Children with extreme premature birth, congenital heart
disease, and fragile X syndrome, for example, display
atypical brain structure and function as well as an increased
risk for ASD (Constantino et al., 2021; Klin et al., 2020).
Social and Cognitive Factors
Investigators have long attempted to identify an essential or
primary cognitive deficit that would account for the atypical
development and impairment observed in autistic children.
The core cognitive skills that have received the most attention
include theory of mind (ToM) and central coherence. As
previously defined and discussed, ToM refers to an ability to
attribute mental states to others. Autistic children and adults
frequently display difficulties with ToM assessments. Even
when autistic individuals are able to understand what others
think, feel, and know, many struggle with appreciating the
ways in which others’ mental states may differ from one’s
own (Deschrijver & Palmer, 2020; Wellman, 2018). The
central coherence hypothesis is based on the idea that most
individuals attempt to perceive and construct meaning
from information that is part of an environmental whole
(Frith, 2012; Frith & Happé, 1994). Information makes
sense, or is coherent, because it is part of something larger
than itself. Autistic youth are at a disadvantage because
they process information piecemeal, in a more fragmented
fashion. When cognitive tasks involve attention to detail,
however, such as identifying embedded figures in a drawing,
autistic individuals do better than non-autistic individuals
(Baron-Cohen, 2010; Johnson et al., 2015). Indeed, the
perceptual functioning of autistic children has sometimes
been described as especially skillful. This is an example of a
strength-based understanding of autism (Frith, 2012).
Baron-Cohen (2010; Greenberg et al., 2018) takes
a somewhat different approach to atypical cognitive
functioning. He describes the empathizing–systemizing (E– S)
theory, which includes below-average empathy (indexed
by poor performance on ToM tasks) and above-average
systemizing. Systemizing is “the drive to analyze or construct
systems” (Baron-Cohen, 2010, p. 129). Rules define systems,
and these rules can be identified or discovered. Examples
include mechanical systems (e.g., locks), numerical systems
(e.g., timetables or calendars), natural systems (e.g., weather
patterns), or abstract systems (e.g., musical notation).
Autistic individuals frequently display a preference or skills
related to systemizing (Greenberg et al., 2018). Although
each of the cognitive factor explanations have empirical
support, research to date has not identified a single, primary
cognitive deficit (Vivanti & Messinger, 2021).
In contrast to explanations focused on cognitive
deficits and differences, social motivation theories of autism
emphasize atypical processes related to social attention,
social engagement, and social rewards. Difficulties in
social communication and social interaction contribute
to frequent and cumulative experiences of atypical
reciprocal social interaction, with adverse impacts on
brain and behavior development. This trajectory leads
to ASD (Klin et al., 2020; Mundy, 2018; Vivanti &
Messinger, 2021). According to these social theories,
autistic infants and toddlers “create their own individual
niches which constrains the environmental realm within
which they will learn …. [They] may miss thousands of
opportunities for social learning every day, and several
million opportunities for social learning within their first
2-3 years of life” (Klin et al., 2020, p. 1181).
A detailed exploration of the foundational social skills
in which initial difficulties or atypical patterns interact
with environmental variation provides support for social
explanations. Developmental cascades for motor/sitting
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
126 Chapter 7 Autism Spectrum Disorder
behavior, visual attention, and sleep contribute to everyday
functioning (Bradshaw et al., 2022). (Bradshaw et al.,
2022). Motor/sitting cascades, for example, influence
multiple domains, including perception, language, and
relationships. Sitting infants have a greatly expanded view
of their surroundings. These expanded views allow for new
and ongoing opportunities for joint attention and social
interactions. Visual attention cascades explain how early
atypical attention patterns impact social attention, social
motivation, and learn ing. Sleep c ascades identif y connections
between sleep and brain development, and describe how
brain organization influences arousal, arousal modulation,
self-stimulatory behaviors, and social interactions.
These developmental cascade models are consistent
with explanations of a developmental substructure for
autism (Constantino et al., 2021). This framework provides
information linking early atypical genetic backgrounds
with biological and psychological processes that lead, over
time, to the emergence of intermediate difficulties—the
developmental substructure—and later to autism spectrum
disorder. Autism, then, “may arise from any number
of distinct disruptions (or combinations thereof) to brain
or developmental processes that contribute to human social
development and behavior (Constantino et al., 2021, p. 367).
Further, the processes that contribute to social deficits,
communication difficulties, and repetitive behaviors are
not independent but “are tightly intercorrelated not only
in individuals with autism but throughout the general
population” (Constantino et al., 2021, p. 368).
Environmental Factors
A variety of prenatal, perinatal, and postnatal environmental
factors have also been investigated. Parental age is associated
with an increased risk for ASD, with both individual and
joint effects for older-aged mothers and fathers (Mandy &
Lai, 2016). Prenatal exposure to valproate (a medication used
for epilepsy, mood disorders, and migraines) is associated
with an increased risk for ASD. Selective serotonin reuptake
inhibitors (SSRIs) appear to be associated with a small
increased risk. Toxic chemicals such as pesticides, phthalates,
and traffic-related air pollutants are all associated with
increased risk. Maternal metabolic profiles related to obesity
and diabetes and the dysregulation of prenatal hormonal
and immune systems increase the risk. Vitamin B9 (folate)
is a prenatal protective factor (Mandy & Lai, 2016).
Perinatal risks include low birth weight, birth difficulties,
and hypoxia. Each of these are nonspecific risks and are
associated with an increased prevalence of a wide range
of neurodevelopmental conditions (Carlsson et al., 2021;
Mandy & Lai, 2016).
Postnatal risks include extreme environmental deprivation,
such as that experienced by infants and toddlers in Romanian
orphanages. Many children reared in institutional settings
display what is sometimes called “quasi-autism.” One
important difference between these children and others
diagnosed with autism is the significant improvement
displayed after they are placed in high-quality foster homes
or with families (Levin et al., 2015). Childhood vaccines and
immunizations have also been repeatedly and convincingly
ruled out as causes of autism (Mandy & Lai, 2016).
Assessment and Diagnosis
As with many other diagnoses, there have been important
changes in the classification and diagnosis of autism
spectrum disorder over time. The transition from the
DSM-IV to DSM-5 in 2013 was such a time for children
and adolescents previously diagnosed with autistic disorder,
Asperger syndrome, or pervasive developmental disorder.
The DSM-5 (continued in DSM-5-TR) revisions to the
diagnostic criteria more meaningfully reflect current theory
and research in ASD. The DSM-5 and DSM-5-TR revisions
have been relevant to youth, families, teachers, and mental
health professionals as they strive to understand particular
children and their particular needs. As we appreciate the
tremendous variability in this spectrum, we are ultimately
responsible for understanding and treating the child, not
their diagnostic label.
The first consideration in assessment is whether the core
symptoms related to social and communication deficits and
repetitive behaviors are present and the degree of impairment
associated with these deficits. Given that complex diagnoses
require complex assessments, interdisciplinary teams that
include medical, psychological, speech and language, and
other professionals provide the most effective evaluations.
Brief screening measures as a part of well-child visits to
general practitioners and pediatricians are now standard.
The American Academy of Pediatrics calls for screening for
autism spectrum disorders as part of well-child checkups at
18 and 24 months of age, with appropriate referrals when
necessary (Hyman et al., 2020). In addition to the screening
that takes place in medical settings, screening tools that are
relatively brief, low cost, and able to be implemented by
paraprofessionals expands access to care in low- and middleincome countries and non-English speaking countries
(Fletcher-Watson et al., 2017; Marlow et al., 2019).
Because early identification is necessary for early
intervention that, in turn, contributes to optimal outcomes,
early screening using a range of methods is an emphasis
for many clinical researchers. Promising examples of these
efforts include the use of detailed parent interviews at 12
months, brain imaging of higher-likelihood infants, and
the use of eye tracking data to identify ASD in very young
children (Clairmont et al., 2022; Meera et al., 2021; Wen
et al., 2022).
These efforts at early identification are in contrast to
prior watch-and-wait practices when a very young child’s
presentation does not yet meet the set of diagnostic
criteria. For example, “two-year-olds with emerging
neurodevelopmental disorders struggle to communicate
effectively, and their communication and behavior restricts
their opportunities to learn and develop. This impacts their
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Assessment and Diagnosis 127
2000 2002 2004 2006 2008 20122010 2014
1,000
Students (in thousands)
Intellectual
parents, who find their behavior perplexing and challenging
to manage” (Constantino et al., 2021, p. 380). Clinical
services for children and their parents are likely to be useful
even before a diagnosis is made.
Interviews, Questionnaires,
and Rating Scales
Parent interviews are often the source of very useful
information, including information about early development, medical history, and family background. A careful
history involves much reliance on parent recall of past
events, and retrospective data are sometimes unreliable.
However, parental concerns must be taken very seriously
because “parents usually are correct in their concerns about
their child’s development” (Filipek et al., 1999, p. 450;
italics in original). Further, “parents rarely complain of
social delays or problems, so any and all such concerns
should be immediately investigated” (Filipek et al., 1999,
p. 452). In addition to parent interviews, the use of flexible
or adapted interviews, questionnaires, narratives, diaries,
and varied communication options—language, signing and
gestures, writing, and images—allow autistic individuals
to participate in their own care (Tesfaye et al., 2019).
These first-person perspectives are a valuable addition to
assessment, diagnosis, and treatment planning.
Several parent-oriented diagnostic questionnaires are
available as well, including t he Modif ied Checklist for Autism
in Toddlers (M-CHAT) and the Autism Behavior Checklist
(ABC) (Campi et al., 2020). The Autism Diagnostic
Observation Schedule (ADOS-2), a semi-structured,
standardized assessment of social interaction, play, and
imaginative use of objects, and the Autism Diagnostic
Interview-Revised (ADI-R), a structured interview, are
widely used in both research and clinical contexts (the
ADOS-2 in particular) (Lebersfeld et al., 2021).
Assessment of intellectual functioning and communication skills are key components of any comprehensive
assessment of ASD (Klinger et al., 2018; Paul & Wilson,
2018). The diagnosis of intellectual developmental disorder
requires special attention because some children are best
diagnosed with intellectual developmental disorder alone,
autism spectrum disorder alone, or both. Keep in mind
that many earlier accounts of autistic individuals included
intellectual delays or disability as part of the clinical
presentation. With comorbidity rates of 33%, we no longer
assume that autistic youth will also be diagnosed with IDD.
Historical trends, in fact, reveal significant shifts in the
prevalence of intellectual disability and autism in students
receiving special education services in the United States
(Thurm et al., 2019, refer to Figure 7.7).
Sociocultural Factors and
Adult Diagnoses
Although standardized assessments work well across
cultures, SES backgrounds, and populations, it is important
to address potential issues related to clinical presentation
and the timing of diagnosis (Rosen et al., 2021). Although
prevalence rates are similar across racial and ethnic
groups, Black, Hispanic, and Asian children in the US are
diagnosed later than White children, as are children from
low-income families (Lord et al., 2018). The majority of
children in low- and middle-income countries who meet
the diagnostic criteria for ASD are undiagnosed (Rosen
et al., 2021). Young children who are girls and who do
not exhibit language delays are diagnosed later (Lord
et al., 2018).
Figure 7.7 Changing trends in special education services provided to students with intellectual
disability versus students with autism
Source: Thurm, Farmer, Salzman, Lord, & Bishop (2019). State of the field: Differentiating intellectual disability from autism spectrum disorder.
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
900
800
700
600
500
400
300
200
100
Austim
Disability
0
128 Chapter 7 Autism Spectrum Disorder
The diagnosis of ASD in adulthood is increasingly
common. Many adults seek an ASD assessment after a child
is diagnosed. Others have concerns related to ongoing social
and employment difficulties. The lack of earlier awareness
and/or prior access to assessment requires attention. In
addition, the complex mental health needs of adults with
a new diagnosis should be addressed (Huang et al., 2020).
Adult versions of ASD interviews are available and have
empirical support (Mandy et al., 2018).
Intervention
Think about the clinical picture of autism spectrum disorder
and how important it is to make the right treatment decisions.
Now consider how parents and teachers of children with autism
must feel as they consider the multitude of treatment options,
some offering slow and steady progress and others promising
miraculous improvements. Information about treatments is
widely available. Mainstream media reports related to autism
include information about empirically supported treatments,
ineffective treatments, and potentially harmful treatments
(Schreck et al., 2013). Parents often seek information and
support from other parents on social media (Pickard &
Ingersoll, 2015). Mental health professionals must work with
parents to make informed, ethical decisions about intervention
for their particular child, addressing concerns about cost, time,
and inaccurate assumptions about evidence-based treatments.
Although concern about autism spectrum disorder is high
in many countries, we also must keep in mind the impact
of culture and ethnicity on attitudes about autism and
interventions. We also note that avail ability and acc ess to highquality services is limited by socioeconomic and demographic
factors and in other countries with fewer resources (Divan
et al., 2021; Lord et al., 2018). Disseminating information
about effective treatments, scaling up services, and training
paraprofessionals to deliver high-quality treatments to diverse
groups of children require the collaboration of researchers,
clinicians, parents, governments, and agencies.
Researchers, clinicians, parents, and autistic individuals
must all think carefully about outcomes (Lounds Taylor,
2017; Pellicano & den Houting, 2021; Vivanti & Messinger,
2021). What are optimal outcomes? What does meaningful
improvement look like? Is it reasonable to work toward goals
that include typical functioning across social-communication
and behavior domains? In addition to interventions for autistic
individuals, how do we address social attitudes and barriers
that get in the way of development and positive outcomes?
What societal accommodations can be provided to support
autistic individuals across all levels of severity? And how do we
include and prioritize the goals of the children, adolescents,
and adults who are diagnosed with autism spectrum disorder?
One final point: Sociocultural factors influence the
accessibility and quality of autism interventions. To improve
access and increase positive connections with parents and
families, outreach materials, intervention design and
implementation, and school and family resources need to be
explained in multiple languages and in culturally respectful
ways (Chlebowski et al., 2018; Kuhn et al., 2020; Stahmer
et al., 2019).
Prevention Efforts
With the identification of an increased risk or high likelihood
of autism for later-born children in families with an autistic
child, prevention efforts or pre-symptomatic interventions
are the focus of research and clinical attention (Grzadzinski
et al., 2021; refer to Figure 7.8). Pre-symptomatic
interventions that take place between birth and 12-18 months
of age raise a number of important questions: (1) How
can improved outcomes in very high likelihood infants be
promoted? (2) Is additional monitoring and screening what
families want? (3) If intervention is initiated, what symptoms
should be targeted? (4) How is treatment conceptualized and
implemented to disrupt the cascading brain and behavior
changes that lead to ASD impairments? (5) What are the ethical
and social implications of early identification and intervention?
Given developmental cascade models, early interventions
are implemented based on risk or likelihood and are timed
to take advantage of maximum neuroplasticity. Presymptomatic interventions typically focus on basic social
processes such as social engagement, attentional biases and
joint attention, sensory regulation, motor skills, and social
communication (Grzadzinski et al., 2021; Klin et al., 2020).
Caregivers are coached to identify, respond to, and scaffold
these social processes over early development. Caregiver
behaviors and interactions are the focus of interventions not
because they are doing something wrong but because their
children require more than typical care.
It is essential to consider the ethics of neuroscience
research into early autism and pre-symptomatic interventions
in the context of relationships between children, parents,
and investigators (Fletcher-Watson et al., 2017; Manzini et
al., 2021). Because the prediction of ASD is probabilistic
rather than deterministic, how are decisions about possible
interventions made in the presence of, for example,
biomarkers revealed by brain imaging (which may or may
not lead to later ASD)? Are pre-symptomatic interventions
designed to move a high likelihood child closer to a
typical presentation or outcome, decrease later distress and
disability, and/or identify alternative positive developmental
pathways by increasing compensatory strategies?
In addition, in baby sibling studies, the research and
clinical attention is on the younger child (who may or may
not develop autism) and not on the older child already
diagnosed with autism. How does this pattern influence
family dynamics? We also need to pay attention to parents’
mental health, their sociocultural milieu, and support
systems. We also must pay attention to the gap between
research and practice. Community-based early interventions
attached to universities or hospitals have better outcomes
than those delivered in other settings (Nahmias et al., 2019).
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Figure 7.8 Conceptual framework for pre-symptomatic intervention
Pre-Symptomatic
Identication of VHL
Infants
• Brain Features (MRI/EEG)
• Genetics/Familial History
• Atypical Behaviors
• Eye Tracking
Sensorimotor & Attention
Problems
Altered Experience Dependent
Neuronal Development
Symptom Emergence
and Consolidation
Intervention 129
Clinical Diagnosis
of ASD
6–18 months oldConception-6 months old
Pre-Symptomatic Intervention Window
Source: Grzadzinski et al. (2021). Pre-symptomatic intervention for autism spectrum disorder (ASD): Defining a research agenda.
Pharmacological Treatment
Given the evidence for genetic and biological factors in
autism spectrum disorder, it is reasonable to examine
pharmac ological i nterventions. For the most part , medications
are not effective in ameliorating the core symptoms of ASD.
A limited number of brain-behavior targets, including the
neurotransmitter and neuromodulatory systems, have been
investigated, but additional data is needed before widespread
use by autistic individuals (Green & Garg, 2018).
Medications are more frequently prescribed to address
comorbid conditions and difficult behaviors such as
irritability and agitation (Lord et al., 2018). There is also
the use of ADHD medications for autistic individuals with
ADHD, but they are not as effective and have more side
effects than in non-autistic individuals with ADHD (Lord
et al., 2018).
Psychological Treatment and Support
Psychological treatments for autism spectrum disorder
have been the focus of theory, research, and controversy.
For decades, applied behavior analysis (ABA), developed
by Ivar Lovaas (Lovaas, 2003), was viewed as the most
effective treatment for more severe forms of autism with
the most empirical support (Leaf et al., 2021). ABA is an
intensive behavioral approach, with high levels of control
and direction of children and their environments. The
approach begins as early as possible and typically involves
more than 40 hours of intervention per week for two or
more years. The focus is first on decreasing negative
behaviors that interfere with social communication and
then on increasing language and peer interaction. ABA
is based on the discrete trial format, with a specific single
behavior presented to the child by the therapist (such as
looking at the therapist’s eyes or engaging in face-to-face
interaction) and then an immediate reward for response
and imitation. Over time, complex behaviors are built from
simple ones.
More recently, there has been a rethinking of ABA’s
methods and goals. Autistic children, for example, are not
passive recipients of interventions. Discrete trial learning is
understood as artificial and not always generalizable to realworld settings. The directiveness of therapists and parents is
often viewed as counterproductive; instead, adult sensitivity
and responsiveness to children’s cues is encouraged. Instead
of the behaviorist focus on “learning rules that apply across
a continuum from young mice to old men,” there is an
appreciation for alternative learning models and opportunities
(Mottron, 2017, p. 817). Side-by-side learning (instead of
face-to-face), or “lateral tutorship,” is often better tolerated by
autistic youth. Overa ll, there is a shif t to more developmentallyinformed treatments for autistic youth, with “affectively rich
interactions, self-driven goals, and in response to the natural
contingencies of their self-initiated behavior” (Vivanti &
Messinger, 2021, p. 4313). These naturalistic behavioral
developmental interventions (NBDIs) include the Early
Denver Start Model and the Treatment and Education
of Autistic (and related) Communication-Handicapped
18–36 months old
Post-Symptomatic Intervention Window
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
130 Chapter 7 Autism Spectrum Disorder
Children (TEACCH) model (refer to Box 7.2). NBDIs are
usually less intensive that ABA but more so than many of the
parent-mediated interventions.
Early parent-mediated interventions are relatively low
intensity interventions that can lead to improvements in
children’s social behavior and communication. Parents
are coached to respond to children’s initiation of activity,
notice opportunities for joint attention, reinforce the
child’s thoughts and communications, and create shared
play experiences (e.g., sitting side by side with a child who
is engaged in a favorite activity), with a goal of increasing
reciprocal social interactions. These interactions are the
basis for meaningful social learning (Lord et al., 2018).
Data suggest that children and parents do best when parents
receive direct coaching with video feedback, increasing
parent-child synchrony and improving later social and
communication outcomes (Green & Garg, 2018; Klin
et al., 2020). We emphasize again that parent coaching is
not done to correct bad parenting but to support parents
as they provide care for vulnerable infants and toddlers.
We also emphasize that parents may provide exemplary
care and their children may still develop a severe clinical
presentations (Klin et al., 2020).
Are there ways to intervene that are based on
developmental principles but also accommodate autistic
children’s preferences and skills and that take advantage
of their own developmental trajectories? Many autistic
children may be able to participate in the co-construction
of treatment goals (Green & Garg, 2018). Given that
autistic children clearly learn on their own, what learning
mechanisms can be identified and built upon? Language
interventions, for example, provide an important
perspective. One assumption in language interventions
is that simple behaviors precede more complex behaviors.
That sequence, however, may be different for many autistic
children. Some autistic children, for example, read before
they speak. Indeed, “autistic children mostly learn language
in a non-communicative manner” (Mottron, 2017, p. 819).
If one of the goals of intervention is to improve social
communication, and autistic children prefer written
communication to verbal communication, then therapists
may want to leverage reading skills by using videos with
subtitles and providing information to autistic children
using screens. Therapists may also want to include sign
language to facilitate communication.
The language intervention example demonstrates
one way in which parents, teachers, and therapists might
build on an autistic youth’s cognitive strengths. Another
way that interventions might be usefully updated involves
re-eva luat ing attitudes toward R BBs. Inter ventions t hat focus
on reducing self-stimulatory behavior, or stimming, might
be reconsidered. Although stimming is often noticeable and
sometimes stigmatized, some stimming appears adaptive
to autistic individuals (Pellicano & den Houting, 2021).
Instead of minimizing or ignoring restricted interests,
therapists might work toward better social communication
skills by recognizing the interests or expertise of each
autistic child. “Just as non-autistic children are exposed to
situations and opportunities that will help them to develop
their intelligence,” therapists should provide “objects that
shine, rotate, or can be lined up” (Mottron, 2017, p. 822).
Interventions to restrict or eliminate behaviors should be
used only when safety is a concern (such as wandering or
self-injurious behaviors).
Another approach to the treatment of various autism
symptoms involves the use of technology. Computers,
tablets, and smart phones are valuable treatment resources.
Apps that prompt children and adolescents with social scripts
or computer-based, serious game interventions that use
components such as strong storylines or rewards to enhance
learning or the generalization of learning are increasingly
used as adjuncts to more traditional treatments (Diener
et al., 2016; Whyte et al., 2015). Like non-autistic youth,
autistic youth also use various technologies for recreation
(Laurie et al., 2019).
Other treatment considerations involve addressing
autism-related difficulties. These may include sleep
interventions (McLay et al., 2021) or interventions
specifically focused on comorbid disorders such as
anxiety, depression, ADHD, or conduct problems.
Across all interventions, a therapeutic alliance must
be established and maintained. The most commonly
used treatments for autistic youth, such as cognitive
behavioral therapy for anxiety, are often adapted with
some modifications to content and implementation
(Dickson et al., 2021; Lord et al., 2018). There is also
increasing attention to mental health concerns that are
not diagnosis-related, such as the difficulties experienced
by autistic individuals who attempt to camouflage their
condition (Manzini et al., 2021). It is imperative to
remember that many interventions for autistic youth may
need to be substantially altered to address the needs of the
individuals with the most severe symptoms and the most
pervasive impairment; these individuals may require more
intensive, more comprehensive, and ongoing treatments
(Vivanti & Messinger, 2021).
School-Based Programs
School-based services are limited by time, resources,
and the availability of trained personnel. All children
who struggle, both with autism spectrum disorder and
without, should be supported in their educational goals.
Many have suggested that school services be decoupled
from DSM diagnoses so the child’s particular learning,
social, and behavioral problems guide eligibility and
individual planning. The most common school services
for children with ASD are cla ssroom placement/inclusion,
supportive services (such as occupational therapy, speech
and language therapy, and social skills interventions),
and special education designation (Spaulding et al.,
2016).
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Intervention 131
There have been significant funds invested in the
education of children with ASD, and the gap between
research on interventions that work and actual educational
practices has yet to be bridged (Parsons et al., 2013).
The Treatment and Education of Autistic and (related)
Communication-Handicapped Children (TEACCH)
model is a comprehensive intervention with convincing
empirical support (Mesibov, 1994, 1997; Schopler, 1998).
The intervention has seven components: (1) improved
adaptation, (2) parent collaboration, (3) individualized
assessment, (4) teaching structure, (5) emphasis on skills,
(6) usefulness of cognitive and behavior therapy, and (7) a
generalist training model (refer to Box 7.2).
About 40% of youth with ASD who qualify for special
education spend 80% or more of their time in mainstream
classrooms. That means approximately 60% of youth
with ASD are only partially included (Odom et al., 2021).
There are many interventions that explicitly target the
acquisition of academic skills in both inclusive and selfcontained classrooms. Communication interventions are
common. There are also group interventions that focus
on social engagement and peer interactions. Technologyassisted instruction and intervention is increasingly used
with positive outcomes (Odom et al., 2021). Encouraging
children’s participation in popular peer activities (such as
sports, music, or art) may be an important strategy that
promotes positive social relationships in elementary school
(Rotheram-Fuller et al., 2010). For youth who struggle with
behavioral difficulties, additional supports may be required.
As described earlier in the chapter, significant efforts
may be made so school settings are less challenging to
navigate for youth with autism. Teachers and staff who
are knowledgeable and skilled about autism-related
practices are more likely to have positive attitudes about
inclusion and about their ability to provide high-quality
educational experiences (Odom et al., 2021; Melgarejo
et al., 2020). The inclusion of toddlers and young children
with autism into mainstream daycare and primary
classrooms may also lead to decreasing stigma and
increasing tolerance in young children without autism,
benefitting all children as they progress through their
school years (Mottron, 2017).
Long-Term Treatment and Support
Autistic children become autistic adolescents who
become autistic adults. With increasing age, intervention
strategies and goals are likely to be revised, with specific
treatments and supports designed for adolescents
and adults (Lord et al., 2018; Odom et al., 2021).
The transition from high school to adulthood may
be difficult if services are not available or in place.
Opportunities for employment, volunteer activities,
and community involvement contribute to positive
pathways. Parents and professionals may need to be
proactive to access services and provide additional
support. Residential options and vocational training
are necessary components of many developmentally
appropriate plans. These are increasingly paired with
available technologies that build on individual strengths
to facilitate personal, social, and vocational skills and
maximize each individual’s potential and well-being
(Lounds Taylor et al., 2022; Scott et al., 2019).
Box 7.2 Clinical Perspectives
The TEACCH Model of Intervention
The TEACCH program, originally developed by Eric Schopler
and colleagues at the University of North Carolina in the
1970s, is a broad-based treatment program for autism that has
become a major intervention approach used in communities
throughout the world (Schopler et al., 1995). Along with other
Comprehensive Treatment Models (CTMs), TEACCH has been
found to be especially effective as an integrated part of the school
curriculum (Mesibov & Hawley, 2018). The TEACCH program
is distinctive in its emphasis on careful individual assessment;
its structured teaching program is based on that assessment
and integrated into all aspects of the day-to-day life of children
with autism spectrum disorder. The structured teaching plan
includes careful organization of the physical environment and
daily schedule as well as clear expectations and rules. In addition,
this approach advocates for increased respect for what is called
the “culture of autism.” Understanding this culture involves
recognizing the unique ways that individuals with autism view
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
their environment and experience the physical and social world.
Interventions, then, are designed to be consistent with this
sensibility. Further, methods that emphasiz e the relative strengths
of autism—such as strong memory, good visual processing skills,
and recognition of details—are utilized and promoted wherever
possible. These treatment principles are then integrated across
systems and settings, including home and school, through
comprehensive services such as social skills training, vocational
training, and parent counseling and training. The TEACCH
model has been adapted for use with ASD populations from
early childhood through adulthood, across cultural contexts,
across levels of disorder severity, and in rural and urban settings
(Coleman et al., 2021; Ichikawa et al., 2013; Van Bourgondien
& Coonrod, 2013; Zeng et al., 2021). Additionally, many of the
principles and techniques of TEACCH, including an emphasis
on a predictable schedule and the use of visual cues, have been
effectively adapted for use in general education.
132 Chapter 7 Autism Spectrum Disorder
Key Terms
Autism spectrum disorder (ASD) (p. 110)
Neurodiversity (p. 110)
Social cognition (p. 111)
Joint attention (p. 111)
Theory of mind (ToM) (p. 111)
Chapter Summary
●
Autism spectrum disorder (ASD) is a broad term that
is used in a variety of contexts, reflecting compromised
development in social functioning and communication
as well as restricted, repetitive behaviors and fixated
interests.
●
Social cognition refers to the many ways that people
think about themselves, others, and their social worlds.
Children with ASD display atypical social cognition.
●
Theory of mind (ToM) refers to the ability to recognize
and represent the mental states and perspectives of others.
It is an example of an important psychological process
that is compromised in many individuals with ASD.
●
Affective social competence—the coordination of
emotional perception, experience, and communication—
is another developmental achievement that is
compromised in youth with ASD.
●
There is a wide variety of clinical presentations of
ASD and equally varied developmental pathways and
outcomes.
●
Dimensional approaches to ASD are the focus of research
and clinical attention. The study of the broad autism
phenotype is an example of the dimensional approach.
Affective social competence (p. 112)
Social and communication deficits (p. 113)
Restricted, repetitive behaviors (p. 115)
Fixated interests (p. 116)
Broad autism phenotype (p. 117)
Applied behavior analysis (p. 129)
Naturalistic behavioral developmental interventions (p. 129)
●
Multiple large-scale studies estimate the prevalence rate of
ASD at 1%. The male:female ratio is approximately 4:1.
●
The core symptoms of ASD are generally evident by two
years of age.
●
Autism spectrum disorder generally presents lifelong
challenges. Symptom severity, the presence of support and
accommodation, and individual differences contribute to
varied outcomes.
●
ASD is a highly heritable condition. Hundreds of genetic
variants and multiple physiological processes contribute
to the development of ASD.
●
Social and cognitive factors, such as atypical social
motivation, contribute to developmental cascades that
help explain the etiology and course of ASD. Several
environmental factors increase the risk for ASD.
●
Early screening and diagnosis provide important
opportunities for early intervention.
●
The varied clinical presentations of ASD require
individualized and comprehensive intervention strategies.
The most successful interventions are those that are
delivered early and intensively across a variety of domains
and settings.
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Maltreatment and Traumaand Stressor-Related Disorders
Chapter Outline
8
Developmental Tasks and Challenges Related to Stress
and Coping 134
Maltreatment 137
The Case of Wyatt
Trauma- and Stressor-Related Disorders 139
The Case of Simone
Box 8.1 Clinical Perspectives:
Disorder
Developmental Course 143
Maltreatment
Box 8.2 Emerging Science: Maltreatment and Depression
Developmental Trauma
Learning Objectives
1. Summarize the organization and development of the stressresponse system.
2. Discuss several ways in which early adversity influences the
stress-response system over time.
3. Summarize the current research on the development of
coping.
4. Define maltreatment and discuss the consequences of
maltreatment over time.
5. Compare and contrast the clinical presentations of acute
stress disorder and posttraumatic stress disorder (PTSD) in
children and adolescents.
6. Summarize the theory and research related to developmental
pathways of youth who experience maltreatment.
The Case of Deion
Trauma- and Stressor-Related Disorders
Etiology 149
Maltreatment
Trauma- and Stressor-Related Disorders
Assessment and Diagnosis 151
Intervention 152
Treatment
Box 8.3 Children in Context: Trauma-Informed Pedagogies
and Classrooms
Prevention
7. Summarize the theory and research related to developmental
pathways for youth diagnosed with acute stress disorder and
PTSD.
8. Evaluate the theory and research related to etiological factors
for youth who experience maltreatment.
9. Evaluate the theory and research related to etiological factors
for youth diagnosed with acute stress disorder and PTSD.
10. Summarize assessment and diagnostic methods and
concerns for youth who experience maltreatment and for
youth diagnosed with acute stress disorder and PTSD.
11. Integrate the information on interventions for youth who
experience maltreatment.
12. Integrate the information on interventions for youth
diagnosed with acute stress disorder and PTSD.
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
133