Assessment and Treatment of Autism Blake M. Lancaster

Michigan State University / Kalamazoo Center for Medical Studies and Western Michigan University, USA

Abstract. Physicians are often the first health care professionals to encounter children that display symptoms associated with developmental disorders such as autism. Unfortunately, there is lack of information regarding what strategies physicians should adopt in treating these symptoms and where they should look to refer individuals who present with severe symptoms of autism. This paper provides some preliminary information regarding the current behavioral assessment and treatment strategies in order to help physicians identify and make appropriate recommendations for successful treatment when working with autistic children. The essential components of successful treatment for autism are outlined; some preliminary treatment methodologies that physicians can recommend parents or caregivers attempt are also highlighted. In addition, the current behavioral treatment strategies used for acquisition of social skills and language are covered as well as methodologies for the reduction of maladaptive behavior in children with autism. [Indian J Pediatr 21)05; 72 (1) : 45-52] E-mail : blake.lancaster@ wmich.edu

Key words: Autism; Behavioral treatment; Functional assessment~analysis; Social skill acquisition; Language acquisition; Behavior reduction Patients who present with symptoms of autism are often difficult to diagnose and treat. Overt manifestations of the disorder as listed in the classification and statistical manuals (Diagnostic and Statistical Manual for Primary Care [DSM-PC] Child and Adolescent Version, 1993; Diagnostic and Statistical Manual of Mental Disorders - 4th edn [DSMI V] 2000; or lnterwational Classification of Diseases - l Oth edn [ICD-IO] 1996) can often be clearly identified. However, physicians may encounter difficulty detecting the more subtle symptoms and signs of autism or autism spectrum disorders; and they may find it difficult to differentiate these symptoms from other mental health diagnoses such as mental retardation, attention-deficit h y p e r a c t i v i t y disorder, schizophrenia, selective mutism, stereotyped movement disorder and obsessive-compulsive disorder among several others.' Physicians also often encounter difficulties that revolve around how to treat and where to refer patients who present with symptoms a n d / o r signs congruent with autism. The purpose of this paper is to briefly describe the issues surrounding the diagnosis of autism, provide some guidance for initial treatment that m i g h t be a t t e m p t e d by physicians and describe the current behavioral procedures for the treatment of autism. This information will hopefully be useful for physicians in helping them make some initial treatment decisions and appropriate referral decisions regarding autism. Prevalence

The n u m b e r individuals diagnosed with autism has Correspondence and Reprint requests : Dr. Blake M. Lancaster, Michigan State University/Kalamazoo Center for Medical Studies, Department of Pediatrics, 1000Oakland Drive,Kalamazoo,M149008 Indian Journal of Pediatrics, Volume 72~January, 2005

dramatically increased in recent years. The prevalence rate for autism has increased from approximately 4 to 1 children in every 1000 children in 1989 to around 4.0 to 6.7 c h i l d r e n in e v e r y 1000 c h i l d r e n in 2003. 2,3,4 These increasing prevalence rates have sparked a plethora of research and theories regarding the best practices for the assessment and treatment of autism. D e f i n i n g Autism

Autistic disorder, commonly referred to as autism, is described as, 'the presence of m a r k e d l y abnormal or i m p a i r e d d e v e l o p m e n t in social i n t e r a c t i o n a n d communication and a markedly restricted repertoire of behavior and interests' and has proven to be a pervasive and challenging disorder to diagnose and treat2 There is a great deal of variability in the severity and presentation of symptomatology across patients, and physicians may have to change, or extend, the way in which they conduct screening for individuals who are suspect for autistic disorders. ~ After the severity of the problem has been established through assessment there are essentially two c o u r s e s that p h y s i c i a n s m a y w a n t to take. If the symptoms do not present a serious functional problem or present danger to the child or caregivers, the physician may want to attempt to treat them. If symptoms present a physical or developmental threat to the child, or less s e v e r e s y m p t o m s persist it is r e c o m m e n d e d that physicians peruse behavioral consultation or refer to a behaviorally based autism t r e a t m e n t provider. The following sections provide guidance as to how physicians may want to approach this process (Tablel 1).

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Blake M. Lancaster Behavioral A s s e s s m e n t and Treatment I s s u e s A u t i s m h a s p r o v e n to be a p a r t i c u l a r l y resilient d i s o r d e r that is d i f f i c u l t to t r e a t ; l a r g e l y b e c a u s e a u t i s m is a syndrome, not a distinct disease entity, and the n e u r o p s y c h o l o g i c a l e t i o l o g y is e s s e n t i a l l y u n k n o w n . 6 This lack of s o u n d information r e g a r d i n g the biological or n e u r o l o g i c a l e t i o l o g y of a u t i s m m a k e s it difficult to treat from a p h a r m a c e u t i c a l s t a n d p o i n t 7 ,s Typically, a clinician treating a p s y c h o l o g i c a l d i s o r d e r from a p h a r m a c e u t i c a l o r i e n t a t i o n w o u l d target the n e u r o - c h e m i c a l s that w e r e h y p o t h e s i z e d to b e r e s p o n s i b l e for the s y m p t o m s , signs and behaviors ,associated with the particular p s y c h o l o g i c a l d i s o r d e r in question. In the case of autism, u n f o r t u n a t e l y , the therapist has little reliable information r e g a r d i n g w h a t . c h e m i c a l s m i g h t b e c a u s i n g the autistic f u n c t i o n i n g (i.e., s y m p t o m s , s i g n s o r b e h a v i o r s ) in the child t h e y are a t t e m p t i n g to treat? T h i s s i t u a t i o n h a s c r e a t e d a d e m a n d for n o n p h a r m a c e u t i c a l l y b a s e d t r e a t m e n t s a n d h a s l e d to the

d e v e l o p m e n t of t r e a t m e n t m e t h o d o l o g i e s in a w i d e v a r i e t y of fields i n c l u d i n g o c c u p a t i o n a l t h e r a p y (sensory i n t e g r a t i o n t h e o r y ) , p h y s i c a l t h e r a p y ( b r u s h i n g ) and n u t r i t i o n ( g l u t e n f r e e d i e t s ) . 9,~~ M a n y o f t h e n o n pharmaceutically based treatments that are currently available for autism, however, are founded upon invalidated theories and unsubstantiated claims r e g a r d i n g the causes of the disorder/1 Behavioral a p p r o a c h e s to the t r e a t m e n t of a u t i s m are currently the most successful, widespread, and e m p i r i c a l l y v a l i d a t e d t r e a t m e n t s for the t r e a t m e n t of a u t i s m . ~2 T h e c e n t r a l e x p l a n a t i o n for t h e s u c c e s s o f b e h a v i o r a l t r e a t m e n t s v e r s u s all o t h e r t r e a t m e n t s for a u t i s m likely centers on the behavioral notion that autistic c h i l d r e n suffer from several difficulties that s t e m from a v a r i e t y of s o u r c e s , a n d t h a t e a c h b e h a v i o r , a n d c h i l d , s h o u l d be a s s e s s e d a n d t r e a t e d i n d i v i d u a l l y . 13 W h e n treating an autistic child from this s t a n d p o i n t , each of the s y m p t o m s of a u t i s m t h a t t h e c h i l d d i s p l a y s a r e

TABI.E1. Autistic Symptoms Identifiable During Well-Child Visits 1,3 Communication Domain

What to Ask Parents "Does your child...

Child does not orient towards his/her name Does not or cannot communicate needs or preferences

respond to his/her name consistently?" gesture? nod yes and no?" show things to others?" have anything odd about their speech?" talk in rigid patterns of words?" use rote, repetitive or echolalic speech?" respond to requests?" respond when you talk to them?" point with their finger?" have anything odd about their language development?"

Language development is delayed Does not respond to parental requests Inconsistent hearing No pointing or waving Language development regression Social Domain

No social smiling Preference for isolated play Gets things for self Is overly independent Poor eye contact In his/her own world Tunes parents out Shows little interest in other children Restrictive I Rigid Behavior Domain

Tantrums Uncooperative / Hyperactive / Oppositional Does not play with toys appropriately Repetitive play over and over Walks on tip toes Abnormal attachment to toys Lines up objects Extremely sensitive to touch or sound Odd movement patterns

"Does your child...

smile back when you smile at them?" play interactively with other children?" prefer to act independently?" show interest in playing with others?" look at you when you talk to them?" uninterested in reciprocal play?" appear to ignore you or not hear you?" show interest in playing with others?" "Does your child...

engage in severe behaviors when they do not get their own way?" cooperate with your requests?" have a restricted range of interests?" engage in normal pretend play?" engage in repetitive, stereotyped behaviors?" walk in any abnormal way?" have excessive preferences for certain toys?" play with toys in any unusual ways?" attend to unusual/superfluous aspects of the toys?" play with toys in any abnormal ways?" seem overly sensitive to touch or sound?" engage in any odd motor behaviors?"

Red Flags For Autism During Initial Screening3: No babbling by 12 months, No Gesturing (pointing, waving, etc.) by 12 months, No single

words by 16 months, No 2 word spontaneous (not just repeating) by 24 months and Any loss of social or language abilities at any time

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Assessment and Treatment of Autism

c o n c e p t u a l i z e d as i n d i v i d u a l b e h a v i o r s , skills, or domains. Conceptualizing the disorder in this way allows treatment providers to implement behavioral treatment strategies that target each problem behavior without being limited by the lack of understanding in regards to the biological or etiological source of the b e h a v i o r problem.

Essential Aspects of Behavioral Treatments There are several features to look for when evaluating a proposed behavioral treatment program for an autistic child. Treatment providers should first identify who is bringing forth the complaint about the autistic child; or w h o is p r o p o s i n g that the child is, in s o m e w a y , p r e s e n t i n g w i t h a p r o b l e m . ~4 W o r k i n g w i t h this individual, and establishing clear treatment goals, is essential step towards conducting ethical and effective treatment when working with autistic individuals. There are several factors that make goal setting an essential step when treating autistic individuals. First, goals should be established by the client and should not be established based on the views of the clinician. A problem solving approach can be useful for ensuring that resources are being dedicated to reaching the client's goals and not e x p e n d i n g u n n e c e s s a r y r e s o u r c e s p u r s u i n g goals congruent with a professional's preconceived notions and "expertise" as to what successful treatment outcomes might look like2 5 In addition, the process of developing clear treatment goals can facilitate the treating physician or psychologist in making treatment selections that are specifically tailored to addresses the goals and concerns of the c o n s u m e r . Lastly, c l a r i f y i n g goals p r o v i d e s information for deciding if the available resources (e.g., time, energy, skills, etc.) are adequate for achieving the goals, or if the client s h o u l d be r e f e r r e d to a n o t h e r clinician who possesses those resources. A n o t h e r essential aspect of b e h a v i o r a l t r e a t m e n t p r o g r a m s involves the collection of data r e g a r d i n g progress towards treatment goals. Collecting data can have a meaningful impact on the success of a particular treatment. First, it provides a systematic and objective m e a n s for e v a l u a t i n g the success of a p a r t i c u l a r treatment. 16 Decision making based on evaluation of progress towards treatment goals through evaluation of data allows treatment providers to make unbiased and accurate decisions r e g a r d i n g the level of p r o g r e s s 2 7 Another benefit is that data collection can provide a visual demonstration of efficacy that may help motivate parents or caregivers to continue implementing a treatment that has demonstrated success over time.

Methods of Treatment That Can be Attempted by the Physician There are a variety of behavioral treatment strategies to select from w h e n a t t e m p t i n g to a d d r e s s p r o b l e m s c o m m o n within the autistic population (i.e., problems centered on social skills, language and restrictive or Indian Journal of Pediatrics, Volume 72--January, 2005

representative behavior problems). These behavioral strategies, though demonstrated to be effective, are also often resource intensive. Physicians can recommend that p a r e n t s or c a r e g i v e r s a t t e m p t s o m e p r e l i m i n a r y adjustments to the child's environment in order to solve the p r o b l e m s b e f o r e r e f e r r i n g the child e l s e w h e r e . Having parents or caregivers implement these treatments can help provide treatments to more autistic individuals, and the t r e a t m e n t goals of each autistic child can be reached more efficiently and, possibly, quickly. TM One m o d e l for the efficient d e l i v e r y of services is referred to as the behavioral engineering strategy2 8 This strategy involves a systematic d e l i v e r y of t r e a t m e n t m e t h o d s in a progression from those treatments that require the fewest amounts of resources to those that require the most. If a treatment goal is achieved at any point during the progression, then further, more resource intensive treatments would not be required. This model is in contrast to the premise that more complicated and involved treatments are better than simple effective ones, and it encourages treatment p r o v i d e r s to i m p l e m e n t simple and effective strategies before resorting to more complex behavioral strategies. There are three aspects of the environment that physicians might recommend for alteration in order to reach treatment goals. The first environmental modification that a physician might target w h e n treating p r o b l e m s that stem from autism is whether or not there is adequate feedback and information for the autistic child in the setting in which the b e h a v i o r access (e.g., m a l a d a p t i v e behavior) or behavioral deficit (lack of communication or appropriate behavior) is occurring, is An evaluation of feedback in the e n v i r o n m e n t should focus on w h e t h e r the behavioral expectations for a given situation are clearly presented, or if they are m i s l e a d i n g or h i d d e n . If it a p p e a r s that feedback might be a contributing factor to the problems, then steps s h o u l d be t a k e n in o r d e r to clarify the b e h a v i o r a l expectations a n d / o r feedback r e g a r d i n g behavioral expectations in a m a n n e r that the targeted autistic child can understand. For example, if an autistic child is placed in an area of the classroom, away from other children, where they cannot hear the directions that are being given to the rest of the class, it will be difficult for them to follow those directions. Furthermore, if the autistic child is in an area away from the teacher, or other students monopolize the teacher's time, it may reduce the amount of corrective feedback that the child receives in regards to their behavior. There are several strategies that might rectify the level of feedback and information that the child c o u l d receive in this e x a m p l e i n c l u d i n g recommending that the child be placed in a group of other children at the same learning level, having the teacher take the time to deliver the instructions directly to the autistic child, or providing quick and clear feedback when the c h i l d ' s b e h a v i o r d o e s not m e e t i n s t r u c t i o n a l expectations. If m o d i f y i n g the level of i n f o r m a t i o n or feedback 47

Blake M. Lancaster

available does not effectively address the treatment goals, physicians might attempt to look at tools that the autistic child is u s i n g and h o w they m a y be influencing the presenting problem. TM If the tools are not appropriate for the performance of a particular behavior that is required, a p h y s i c i a n m i g h t instruct p a r e n t s or caregivers to modify, replace or add an additional tool in order for the autistic child to complete the required task. A case in which an autistic child might need additional or adaptive tools might include a situation in which the child was having difficulty using a spoon to deliver food from a plate to their m o u t h without d r o p p i n g it. Instead of expending the numerous resources that may be necessary to train the child how to use a typical spoon correctly, the physician might recommend that modifications be made to the physical features of the utensil the child was attempting to eat with. For example, the spoon could be modified by increasing the size of the handle or the shovel to make it easier for the child to deliver food from the plate to their mouth without spilling. A final environmental factor that should be evaluated, before intense behavioral treatments are implemented, is m o t i v a t i o n . F r o m a m o t i v a t i o n a l s t a n d p o i n t it is imperative that some form of incentive be available for performances that meet instructions, and consequences for those behavior that do not meet established behavioral standards. TM Overall, physicians should look for factors that may inhibit autistic children's capacity to absorb and access n e w information or knowledge by asking themselves, "is there anything that can be easily altered to increase this child's ability to gain knowledge from the environment?" For example, flexible s c h e d u l i n g for a child's daily regimens may help ensure that the learning trials occur when the child is at their sharpest (i.e., not first thing in the morning or right after lunch. Often, modifications of this nature are overlooked, possibly because the autistic child m a y not h a v e the skills to c o m m u n i c a t e their inability to hear or see. These handicaps, however, clearly can c o n t r i b u t e to a child's difficulties and failure to address these issues may lead to high levels of frustration and increased levels of maladaptive behaviors such as aggression or property destruction. In clinical practice, the efficacy of these environmental treatment approaches (i.e., modifying the information, the tools and the motivation available) should always be evaluated using objective measurements to determine which method is most efficient in achieving treatment goals. For example, in the case of modifying the physical features of the spoon, the physician may ask parents to keep track of the percentage of food presented to the child and the percentage of food consumed independently. These simple and logical treatments should be evaluated objectively before referring the child and their parent's elsewhere to ensure that the least restrictive treatments are attempted when striving towards clinical goals. None of these treatment approaches, however, are directed at 48

m o d i f y i n g the b e h a v i o r r e p e r t o r i e of the autistic individual, which requires substantially more resources and expertise. Identifying Programs

Appropriate

Behavioral

Treatment

If the aforementioned methods of treatment, through the modification of the environment, have failed to produce a level of behavior that is consistent with the treatment goals it may be necessary for physicians to refer to a behavioral specialist who will likely begin the process of altering the autistic child's repertorie of behavior. The p r o c e s s of m o d i f y i n g the autistic c h i l d ' s b e h a v i o r r e p e r t o r i e is often resource intensive; h o w e v e r , it is imperative that the severe symptoms and signs of autism be addressed fully in order for autistic children to make real progress towards becoming an active, independent and functional m e m b e r of society. When referring an autistic child for t r e a t m e n t of s e v e r e s y m p t o m s , physicians should consider including the data that they have had parents collect regarding treatment efficacy and report the methods that they have employed in order to alleviate the problems. Most behavioral treatment sites will utilize this data to gain some preliminary assessment information regarding the child's behaviors and may use it to develop some h y p o t h e s e s about what treatment approaches might be effective. Some of the methodologies that are often i m p l e m e n t e d in effective b e h a v i o r a l t r e a t m e n t p r o g r a m s are d e s c r i b e d in the f o l l o w i n g sections. These methodologies represent the practices that physicians should look for, or advocate for, within potential referral sites for children suffering from severe symptoms of autism.

Discrete Trial Training & Component Analysis Discrete trial training involves teaching each component of "target" behavior using a procedure where the child is p r e s e n t e d a s t i m u l u s (e.g., p r o m p t , q u e s t i o n or command) that indicates to him that a particular response is w a r r a n t e d . If the child r e s p o n d s to the s t i m u l u s correctly (e.g., the handing over of a communication card, or the u t t e r a n c e of a s o u n d or w o r d ) some form of reinforcement (e.g., tangible items such as edibles, tokens or other small preferred items) is provided for the child2 ~ If the child is unable to perform the behavior required to receive r e i n f o r c e m e n t d u r i n g a p a r t i c u l a r trial, the behavior is typically modeled for him and he is physically g u i d e d to c o m p l e t e the b e h a v i o r . This g u i d a n c e procedure exposes the child to the aspects of the "target" b e h a v i o r that will allow him to access r e i n f o r c e m e n t independently during future trials. Discrete trial t r a i n i n g p r o c e d u r e s are t y p i c a l l y introduced following a component analysis in which all essential aspects of the desired behavior (e.g., language or social skirls) are identified as separate elements. The child is then taught each element individually and sequentially in a discrete trial training format to build the foundation Indian Journal of Pediatrics, Volume 72---January, 2005

Assessment and Treatment of Autism

necessary for the performance of the complex behaviors i n v o l v e d in b o t h social skills and c o m m u n i c a t i o n . T h o u g h the resources required for the p r o c e d u r e are extensive, this level of one-on-one, discrete trial training, attention, is essential because it allows the therapist to the provide the child with the numerous number of learning trials necessary in order to build a solid foundation of behaviors that will support the development of higher level language and communication skills.

communication during a play period of approximately 30 seconds. F o l l o w i n g this p l a y i n t e r v a l the child is prompted to give the item back to the caregiver, the array is presented again, and the process is repeated. This is done in an interactive way with the caregiver and allows the children to begin bqilding turn taking skills while p r o v i d i n g s i m u l t a n e o u s learning trials d e s i g n e d to increase their ability to generalize their language skills to a natural play setting. 24

Language Acquisition

Social Skills

When teaching communication skills, practitioners will usually assess the child's current communicative abilities, and use this as a s t a r t i n g p o i n t for t e a c h i n g c o m m u n i c a t i o n skills. Language assessment is often conducted using psychometric tests that are designed to assess the c u r r e n t level of l a n g u a g e d e v e l o p m e n t compared to other children of similar ages. Some autistic children may not have the ability to engage in any vocal verbal behavior, and in these cases the first step is to expose the autistic child to the natural benefits associated with communication. In order to do this, behavioral t h e r a p i s t s will o f t e n e m p l o y a p i c t u r e e x c h a n g e communication system (PECS) in which the child receives reinforcement contingent upon delivery of a card with a picture of an object on it. ~ For example, an autistic child might be presented an array of pictures of preferred items, and when they hand one of the pictures to the therapist t h e y receive the item p i c t u r e d on the card. This methodology is often taught using a discrete trial training method to help expose autistic child to the fact that they can receive r e i n f o r c e m e n t from o t h e r s t h r o u g h communication, which is an essential component when attempting to achieve the ultimate goal of unprompted, independent, verbal communication within the natural e n v i r o n m e n t . 2~ Technologies, such as PECS, e x p o s e autistic children to this intrinsic value of communication without requiring them to master the complex muscle control needed to perform vocal communication. Discrete trial training has proven to be an effective m e a s u r e in b u i l d i n g the initial b u i l d i n g blocks of language, but the skills taught during this procedure can often be difficult for an autistic child to generalize to the n a t u r a l e n v i r o n m e n t . 22 One t e c h n i q u e for t e a c h i n g language to autistic children in a way that will transfer to "real world" situations is incidental teaching or natural learning paradigm (NLP). These strategies consist of caregivers setting up a situation in which highly preferred items are available to the autistic child in an array of approximately 10-15 items23 The child is then encouraged to sign for one of the items using whatever means of socially appropriate communication (i.e., not maladaptive b e h a v i o r such as s c r e a m i n g or aggression) that he currently possess. Once child engages in a reasonable form of communication for his current developmental level, he receives access to the item, and the caregiver takes the opportunity to introduce a few new forms of

Behavioral treatments for autistic children with social skill deficits are based on several of the same principles that are u t i l i z e d for the t r e a t m e n t of c o m m u n i c a t i o n or l a n g u a g e deficits. The first steps of a social skill a c q u i s i t i o n p r o g r a m , as w i t h l a n g u a g e p r o g r a m s , typically consists of a c o m p o n e n t analysis in order to identify what specific aspects of the social skill repertorie a child might be lacking. Next, a discrete trial training c u r r i c u l u m is d e v e l o p e d to t e a c h t h e c h i l d t h e fundamental skills upon which higher-level social skills can be developed. For example, the curriculum might focus on d e v e l o p i n g the c h i l d ' s ability to m a k e a p p r o p r i a t e eye contact, teach the child a script for introducing themselves to peers or teach them turn taking skills within a conversation. Again, these skills would typically be introduced initially in a discrete trial format until they are mastered, and the focus of therapy would then typically shift towards helping the child implement these skills in the natural environment. Most of the strategies designed to help children with a u t i s m g e n e r a l i z e their social skills to a n a t u r a l environment involve the use of confederate peers within a semi-structured role-playing setting, z~A semi-structured setting might include playing a board game, or working together on a project. The setting should include s o m e form of predetermined interaction (i.e., communication through playing a board game) so that the children do not have to make their own conversation, as the a u t i s t i c child's social difficulties will likely surface in a setting in where the social "norms" are unclear or ambiguous. Physicians should advocate for or recommend those behavioral treatment sites that dedicate an e x t e n s i v e amount of time to the training of confederate peers as to how they should to the autistic child. If confederates do not respond in a socially reinforcing manner, or if they do not respond at all, they could potentially extinguish or p u n i s h the autistic child's n e w l y l e a r n e d s o c i a l behaviors. 26 This issue can be overcome relatively easily by making sure that an extensive amount of attention is paid to training confederate peers at potential treatment sites. 27 It is also recommended that physicians locate sites or advocate the use of more than one confederate peer in these semi-structured settings in order to help p r o m o t e the g e n e r a l i z a t i o n of the social b e h a v i o r s to o t h e r individuals outside the training context. 2a

Indian Journal of Pediatrics, Volume 72--January, 2005

Acquisition

49

Blake M. Lancaster Behavioral Reduction

Programs

Physicians are likely to e n c o u n t e r complaints f r o m the c o n s u m e r that revolve a r o u n d behavioral excesses in the autistic child such as self-injurious behavior, aggression, d i s r u p t i o n , a n d s t e r e o t y p y or s t e r e o t y p i c b e h a v i o r . Several of these maladaptive behaviors m a y stem directly from the s y m p t o m s of autism and can be the result of the d i f f i c u l t i e s t h a t an a u t i s t i c c h i l d m i g h t h a v e in c o m m u n i c a t i n g his n e e d s a n d desires effectively, his i n a b i l i t y to a d a p t well to c h a n g e s in s c h e d u l e s o r activities, and his desire to escape aversive situations (i.e., school w o r k , d a i l y living skills, or c h o r e s a r o u n d the house). These b e h a v i o r s s h o u l d be a h i g h priority for treatment, n o t s i m p l y b e c a u s e of the o b v i o u s s a f e t y / health issues s u r r o u n d i n g them, b u t because they can i n t e r f e r e w i t h the p r o g r e s s o f b e h a v i o r a c q u i s i t i o n p r o g r a m s d e s i g n e d to help i m p r o v e the autistic child's

communication or social skills. Treatment strategies that address behavior excesses are d e s i g n e d to i n t e r r u p t the r e l a t i o n s h i p b e t w e e n the maladaptive behaviors and the environmental variables that function to maintain them/9 The procedures involved in i d e n t i f y i n g the r e l a t i o n s h i p b e t w e e n m a l a d a p t i v e behaviors and the variables that serve to maintain them are r e f e r r e d to w i t h i n the b e h a v i o r a l c o m m u n i t y as functional assessment strategies. These assessments are some of the most resource intensive aspects of behavioral t r e a t m e n t s for c h i l d r e n w i t h a u t i s m . 3~ ~ F u n c t i o n a l assessment and function based treatments, however, s h o u l d be vigorously s o u g h t out or advocated for w h e n an autistic child presents with m a l a d a p t i v e b e h a v i o r s because they are extremely effective for determining w h y a particular b e h a v i o r is occurring and greatly increases the probability of a successful treatment outcome. 31

Developmental concerns stemming from the parent, caregiver, teacher, or physician

Screen for Developmental Problems using questions from Table 1 and psychometric measures.

If development is not normal, screen for autism through referral.

I

If development is normal, continue to monitor development during regularly scheduled visits.

Conceptualize problems as behavioral in nature and use simple environmental manipulations to solve, using data collection to evaluate and guide treatment.

Presence of autism

If autistic, determine where problems are specifically (i.e, social skills, language, restrictive or repetitive behavior).

Conceptualize specific problems as behavior excesses or deficits and attempt to make simple environmental adjustments while collecting objective data. If unable to treat independently refer to behaviorally based programs on nature of behavior. If behavio!al excess (e.g., repetitive or maladaptive)

Refer to behavioral program that offers functional assessment and functional analysis to develop function based treatments. Send data collected and treatments attempted with referral.

( If behavioral deficit (e.g., lack of social or language skills)

Refer to behavioral program that offers component analysis & discrete trial training while training child to generalize of skills to natural environment. Send data collected and treatments attempted with referral.

Fig. 1. Assessment and Treatment Flow Chart ~-~.~6 50

Indian Journal of Pediatrics, Volume 72---January, 2005

Assessment and Treatment of Autism Functional Assessment

The term functional assessment describes a variety of p r o c e d u r e s d e s i g n e d to e x a m i n e the r e l e v a n t e n v i r o n m e n t a l variables that function to m a i n t a i n or perpetuate problem behavior. 32In short, they are designed to identify those variables that maintain problem behavior (Fig. 1). One of the simplest type of functional assessment is r e f e r r e d to as n a r r a t i v e a s s e s s m e n t , or A-B-C d a t a collection (Antecedent - Behavior - Consequence), which involves recording the events that take place immediately p r i o r to and f o l l o w i n g instances of target b e h a v i o r . S o m e t i m e s a c h e c k l i s t v e r s i o n of this p r o c e d u r e is implemented because data can be difficult to quantify and interpret when using a "free-form" narrative approach. ~ O t h e r f u n c t i o n a l a s s e s s m e n t strategies, t h a t e x p e r t b e h a v i o r analysts will s o m e t i m e e m p l o y , involve an experimental procedure where the potential maintaining variables are experimentally manipulated to determine which ones might be maintaining problem behavior. 29 A r e c e n t d e v e l o p m e n t in f u n c t i o n a l a s s e s s m e n t methodology is the use of standardized checklists such as the Motivation Assessment Scale (MAS) or the Questions A b o u t B e h a v i o r a l F u n c t i o n (QABF) that s c r e e n for behavioral function 34,3s. These forms include specific q u e s t i o n s a b o u t e n v i r o n m e n t a l events that e x a m i n e s e v e r a l p o t e n t i a l social a n d non-social m a i n t a i n i n g variables for problem behavior. They provide a simple and efficient assessment procedure that can be used by i n d i v i d u a l s w h o do n o t h a v e e x t e n s i v e t r a i n i n g in functional assessment procedures? 6 Function Based Treatments

In addition to advocating for functional assessment when confronted with behavioral excess problems, physicians s h o u l d look for sites t h a t b a s e the d e v e l o p m e n t of treatment on the results of these assessment procedures. Most behaviorally based treatment programs designed to t r e a t b e h a v i o r excesses will select t r e a t m e n t s b a s e d h e a v i l y on the h y p o t h e s i z e d f u n c t i o n of the t a r g e t behavior. Specifically, function based treatments are selected b a s e d on h o w well they m i g h t i n t e r r u p t the r e l a t i o n s h i p b e t w e e n the p r o b l e m b e h a v i o r a n d the reinforcer or reinforcers hypothesized to maintain that b e h a v i o r 7 When implementing these sometime invasive s t r a t e g i e s , h o w e v e r , it is i m p o r t a n t that t r e a t m e n t providers also take into account the preferences of parents or caregivers, the preferences and abilities of the autistic child, the level of supervision that can be expected of the child f r o m the caregiver, as well as the u r g e n c y with which the rate of the target behavior must be reduced (i.e., life threatening behaviors, such as pica, should be treated very aggressively). F u n d a m e n t a l s of the Behavioral Approach

There are two f u n d a m e n t a l aspects of the b e h a v i o r a l Indian Journal of Pediatrics, Volume 72~anuary, 2005

approach in assessing and treating children w h o might suffer from autism. First, treatment goals should be based on the problems that the consumer (i.e., family a n d / o r caregivers) brings forth and be jointly developed by the treating p r o v i d e r and the c o n s u m e r ; not the treating professional alone. Second, treatment providers should c o n c e p t u a l i z a t i o n s y m p t o m s and signs of a u t i s m as behavioral problems because it helps define specific goals, provide specific targets for treatment, and empower and m o t i v a t e c a r e g i v e r s to i m p l e m e n t t r e a t m e n t . Furthermore, by conceptualizing s y m p t o m s as behavior problems the treatment team (i.e., parents, caregivers, physicians, psychologists, etc.) allows for more accurate data collection, which is an essential resource for the team to rely upon for making unbiased judgments regarding the efficacy of various treatment strategies. Data collection is the foundation upon which decisions are made throughout the treatment process to determine whether the physician, alone, can treat the problem or if m o r e e x p e r t i s e m a y be n e e d e d in o r d e r to treat the problem. Relying on the subjective report of caregivers a n d or p a r e n t s for i n f o r m a t i o n r e g a r d i n g t r e a t m e n t efficacy can be a critical error in the treatment of autism. Ultimately, the only way to ensure real progress in the d e v e l o p m e n t of autistic children is to collect empirical, unbiased, data regarding the effectiveness of treatment in progressing towards treatment goals. REFERENCES 1. Volkmar F, Cook EH, Jr. Pomeroy J, Realmuto G, Tanguay PP Parameters for the assessment and treatment of children, adolescents, and adults with autism and other pervasive developmental disorders. J Am Academy of Child & Adolescent Psychiatry 1999; 38 : 32-54. 2. Burd L, Fisher W, Kerbeshian J. A prevalence study of pervasive developmental disorders in North Dakota. Academy of Child Adolescent Psychiatry 1987; 26 : 700-703. 3. Ritvo ER, Freeman BJ, Pingree C, Mason-Brothers A, Jorde L, Jenson WR et al. The UCLA-University of Utah epidemiological survey of autism: Prevalence. Am J Psychiatry 1989; 146 : 194-199. 4. Bertrand J, Mars A, Boyle C, Bove F, Yeargin-Allsopp M, Decoufle P. Prevalence of autism in a United States population: the BrickTownship, New Jersey, investigation. Pediatrics 2001; 108 : 1155-1161. 5. Filipek PA, Accardo PJ, Ashwal S, Baranek GT, Cook EH, Jr, Dawson Get al. The screening and diagnosis of autistic spectrum disorders. JAutism and Developmental Dis 1999; 29 : 439-484. 6. Pelios LV, Lund SK. A selective overview of issues of classification, causation, and early intensive behavioral intervention for autism. Behavior Modification 2001; 25 : 678-679. 7. Filipeck PA, Accardo PJ, Baranek GT. The screening and diagnosing of autism spectrum disorders. J Autism and Developmental Dis 1999;29 : 437-481. 8. Volkmar FR. Pharmacological interventions in autism: Theoretical and practical issues. J Clinical Child Psychology 2001; 30 : 80-87. 9. Kranowitz CA, Silver LB. The out-of-sync child: recognizing and coping with sensory integration dysfunction. New York: 2002; Skylight Press. 51

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Indian Journal of Pediatrics, Volume 72---January, 2005