Managing Autism in Children

No other psychiatric diagnosis has more profound negative implications than autism. On the surface, autism impacts social, emotional, behavioral, and academic functioning. However, autism is pervasive in ways less immediately observable, and, as a result, children with autism require developmental and educational interventions that are different in both form and intensity from those required by children with other special needs.

Finding the appropriate intervention is difficult. A parent must first have an in-depth understanding of the diagnosis because, to be of benefit, interventions need to be geared to the individual child.¹ Assessing general intellectual and developmental functioning and the presence of comorbid disorders is a first step in identifying appropriate interventions. This is best accomplished by a multidisciplinary approach, and guidance and coordination by the psychiatrist is crucial.

Psychiatrists must also address the parents' functioning and adjustment to the diagnosis: prolonged reactions of shock, denial, helplessness, guilt, anger, grief, and resentment interfere with the parents' ability to negotiate the many obstacles they will face in securing effective services for their child, not just initially, but over the course of their child's life. Parents will find that the most sought-after and proven programs (such as those that primarily use the principals of applied behavioral analysis [ABA]) are limited in availability because of fund- ing issues, waiting lists, or geography. Adding to the stress is that time is of great importance; there is substantial evidence that early and appropriate intervention is strongly related to better outcome.

For psychiatrists to advocate for these children, it is necessary to become familiar with why these chil-dren need specific and intensive ser- vices, how these interventions are applied, and what the outcomes are of these treatments.

Children with autism have fundamental and pervasive differences in their readiness and ability to learn.² While the nonautistic, developmentally delayed child will need special assistance to learn, the autistic child must first "learn to learn." Most intellectually impaired children have a consistent learning trajectory. They may learn more slowly, and their ultimate level of achievement may be less than average, but they possess an innate ability and interest to attend to their surroundings in a manner that sets the stage for learning to occur. Disorders such as depression or anxiety in children may interfere with optimal learning and functioning, but children with depression or anxiety disorders are not pervasively compromised in the fundamental skills. Children with autism lack such fundamental skills, and the consequent learning disabilities can be numerous (Table 1).

Limited sustained attention in children with autism consistently and negatively impacts not only their pace and persistence with tasks (a primary limitation) but also their basic ability to benefit from exposure and experience. Children with autism may engage in stimulus selectivity by focusing on a particular object or stimulus to the exclusion of others. Verbal stimuli, the source of most learning experiences at home and in school, are often of little interest. Children with autism are often distractible because they are easily overwhelmed by external and internal stimulation, which they cannot decipher or modulate. The ring of a telephone may set off reactions ranging from overactivity (responding to everything) to withdrawal (tuning out and avoidance). Their inability to prioritize relevant stimuli is another deficit.

Autistic children are poor respond- ers to external or internal rewards. They have little self-awareness and, therefore, do not experience the natural pride that comes with success. Autism also interferes with a child's sense of the bigger picture—understanding why learning is important. With circumscribed interests, even rewards that are commonly sought out by other children (eg, toys, praise) are initially of little value to children with autism.

Many children with autism must be taught to do what comes naturally to their more typical peers, namely initiate meaningful, planned, and playful interactions with their surroundings. For most children, the joy of play-related learning comes from 2 sources: the pleasure of engaging in the behavior and the result of their accomplishments. They learn to generalize their play experiences to the broader world. Play also encompasses imitation, another skill deficit in children with autism, who have to be taught to attend to and mirror others.

As a result of neurobiological development and the benefit of instruction, over time, most children mature into abstract thinkers. Abstract thinking in young children does not equate with the ability to sort out complex motivations. Instead, one aspect of abstract thinking translates into seeing an action as a means to an end. Children with autism generally do not have this understanding, and their motivation for learning a behavior is limited. In addition, children with autism are limited in their ability to enjoy and benefit from representational play. They are unable to recognize that a toy, picture, or symbol is a representation of something in real life that can be used for learning and and something that they can engage in.

Mental retardation and anxiety disorders are the most common comorbidities with autism, although attentional and communication deficits are of significant concern as well. Even mild general cognitive delays hamper the limited learning abilities of many children with autism. Symptoms of anxiety may be partially related to the specific neurobiological makeup of these children, but whatever the cause, avoidance of novel situations and insistence on routines are clearly related to anxiety. Emotional dysregulation and deficits in receptive and expressive language may result in anxiety and frustration. Tantrums and/or aggressive behaviors are also obstacles to learning.

ABA is not a specific technique or treatment. Rather, it is an approach to learning that focuses on the acquisition of skills to enhance attention, communication, imitation, play, activities of daily living, and socialization. The principles of ABA have been used to enhance competence, functioning, and prosocial behavior in a wide variety of populations and contexts, and this same approach has been used to address the symptoms of autism. Although programs for children with autism that use the science of ABA are casually referred to as "ABA programs," this term does not describe a specific program.

ABA is an ordered, sequenced approach to learning that can be measured and quantified. The broad goal is to maximize the child's behavioral repertoire and solidify his or her ability to learn from instruction and experience. ABA techniques can address each of the skill deficits that interfere with the developmental trajectory of an autistic child. Unlike the typical school environment (although some programs are in public schools), programs for children with autism, especially those with a behavioral focus, recognize that the visual and physical environment of even a special classroom may be too chaotic for a child with autism, resulting in maladaptive behaviors and routines that are damaging to learning and difficult to extinguish.

While other programs also incorporate approaches to behavioral change, ABA is characterized by techniques that are focused on the acquisition of skills and that create a successful learning environment. The approach is geared to the individual child through a careful, ongoing, and objectively measured assessment of the child's abilities, needs, interests, and progress. As noted in a 1999 report on mental health by the Sur-geon General, David Satcher, "Thirty years of research has demonstrated the efficacy of applied behavioral methods in reducing inappropriate behavior and in increasing communication, learning, and appropriate social behavior."³

Programs for children with autism that use ABA are based on a carefully crafted instructional plan, and it is assumed that parents will contribute to its development with their observations and opinions. Many comprehensive and readily understandable guides to program development are available to parents, teachers, and clinical interventionists, although even the most motivated parent or teacher needs intensive training to successfully implement behavioral treatment.^4,5 Table 2 presents sample questions that should be considered in instructional planning.

Discrete trial training (DTT) is a unit of instruction that is generally implemented one-on-one in a distraction-free setting. It uses behavioral terminology to describe instruction but translates it to easily understandable terms. DTT uses "discriminative stimulus," simply the instruction, "Stack, please!" followed by a response (the child stacking, not stacking, or doing something else), and the consequence or reinforcing stimulus (usually a reward if correct) or a response by the instructor that the child's response is incorrect (silence, "Nope!," prompting, or other direction by the instructor). The child's response should occur in 3 to 5 seconds and should consist of the "target" behavior.