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Tuesday, April 26, 2005
Parenting
Infants can show early signs of autism
Study your baby's reactions for clues to a disorder that is on the rise.
By Shari Roan / Los Angeles Times
Child development experts may one day be able to identify children at risk for autism before their first birthdays.
According to the Centers for Disease Control and Prevention, an estimated 1.5 million Americans have an autistic disorder, with the incidence growing by 10-17 percent
a year since the early 1990s. Researchers are beginning to study infants who are the younger siblings of autistic children. Earlier studies have shown that when one child in a family has autism, the risk of the disorder in a younger sibling increases by an estimated 10 percent to 20 percent.
Even infants as young as 6 months can be screened for potential warning signs, some experts say. For example, while all 6-month-olds like to gaze at objects that interest them, autistic babies may focus solely, and repeatedly, on a single object; their parents may have difficulty redirecting their attention. Also, 6-month-olds ordinarily enjoy gazing at faces, especially their parents', Filipek says. Autistic babies, however, often avoid eye contact.
"When you hold a newborn or a 2-month-old, that baby is mesmerized by your face," says Dr. Pauline Filipek of Orange, Calif.. "That baby can stare at your face and will stick his tongue out at you and imitate you. They coo. By age 4 or 5 months, you should be able to have a 'conversation' with that baby."
Autism appears to involve problems reading and decoding information from a person's face, says Geraldine Dawson, director of the Autism Center at the University of
Washington's Center on Human Development and Disability. In one study of 3-year-olds, Dawson monitored the brain activity of children as they were shown pictures of their mothers and of strangers. Autistic children showed no reaction to their mothers' faces as compared with strangers' faces. "Face recognition is one area we're interested in," she says. "These are behaviors we should be able to pick up early."
Researchers also are looking at how babies respond to speech. Babies seem to prefer listening to their mothers' speech more than nonspeech sounds. An autistic child, however, may not show such a preference. "We may not be able to diagnose autism with this, but we could pick up a child at risk," says Dawson. Experts caution that more research is needed before doctors can reliably diagnose autism in infants or babies. Today, most children with autism are evaluated using diagnostic instruments designed for 3- or 4-year-olds. There are no standard criteria for diagnosing the disorder in children ages 1 or 2.
Experienced autism researchers can usually determine whether a 2-year-old child is on the "autism spectrum," but they can't predict the severity of the disorder, says Dawson. Besides the wide variation in severity, children with autism can differ in many ways. Some are mentally retarded or have feeding problems or poor muscle tone, while others lack these characteristics.
Behaviors to watch
The criteria used to diagnose autism are designed for 3-year-olds. Recent research shows certain behaviors in younger children may indicate a higher risk for developing the disorder. No single factor indicates a child may have autism; the presence of several symptoms could be cause for concern.
Possible symptoms at 6 months:
• Not making eye contact with parents during interaction
• Not cooing or babbling
• Not smiling when parents smile
• Not participating in vocal turn-taking (baby makes a
sound, adult makes a sound, and so forth)
• Not responding to peekaboo game
At 14 months:
• No attempts to speak
• Not pointing, waving or grasping
• No response when name is called
• Indifferent to others
• Repetitive body motions such as rocking or hand
flapping
• Fixation on a single object
• Oversensitivity to textures, smells, sounds
• Strong resistance to change in routine
• Any loss of language
At 24 months:
• Does not initiate two-word phrases (that is, doesn't just echo words)
• Any loss of words or developmental skill
Source: Rebecca Landa, Center for Autism and Related Disorders at the Kennedy Krieger
Institute, Baltimore
Los Angeles Times
SLP and ABA in ASD: Sorting Out the Issues
By Suzanne M. Harris, MS CCC-SLP
Speech-Language Pathologist/Private Practice
In a previous issue of the VOICE, Joseph Vedora provided an informative summary of the ABCs of ABA, called, “Applied Behavior Analysis: What is it really?” In the second paragraph of his article, he raises the question of why so many “educators” are opposed to ABA, given its relative basis in empirical research. As a pediatric Speech-Language Pathologist, I work with children who have a variety of communication issues, including those diagnosed as on the PDD/Autism spectrum. My own past experiences have left me with questions and concerns about the use of ABA, and the difficulties seen in mixing Speech-Language Pathology and ABA. My hope is that by providing a different point of view, a productive dialogue can be initiated that will further the quality of services offered to this special population of children and their families.
In the past, I have worked with several different ABA programs, and a variety of staff. The children that were the center of these teams were quite diverse, and yet many of the same issues surfaced in all of these cases. In an effort to better understand what ABA is, and how it is designed to support children that I work with, I began to talk with colleagues, including Melanie Olson-Giles, whose article appears here as well. She provided me with excellent resources and articles, through which I was able to find a great deal of information about the philosophical basis for this treatment approach. As I began to critically evaluate this information, I was surprised to find many parallels between our professions. I have outlined several below:
Use of Learning Theory: There is much information in the literature about the role of ABA in determining HOW we teach children; the premise being that ABA can provide this missing link for clinicians. However, even in the earliest stages of my undergraduate training, I was exposed to learning theory. Both of our professions utilize knowledge about how children acquire new skills, including chaining, branching, and use of reinforcers and schedules. Without these techniques, we would not be able to facilitate a child in reaching many of their speech and language goals.
Use of a variety of learning contexts: Although ABA has a reputation of being all about discrete trials, our professions are more similar than one might think. In Speech-Language Pathology, as in ABA, we often move from more structured contexts to more natural ones. We seek to generalize a learned skill across partners and settings. We must help a child begin to monitor their own performance and fade prompts and supports over time.
Viewing Behavior as Communication: This is an issue of critical importance. As Speech-Language Pathologists, we are specifically and highly trained to evaluate how children are communicating through their behaviors. Thus, we are often skilled at looking at a child’s behavior, and determining what they may be expressing (frustration, fatigue, requesting) through whatever skills they have. Vedora’s example about mouthing illustrates this well. A child may be exhibiting a particular behavior for several reasons. If we can understand its function, we can find ways to address the behavior that actually may affect its frequency, as well as find ways to replace a less sophisticated or conventional behavior with one that is social and communicative. How well we read a child’s attempts at communication (no matter how primitive) and respond to them can have a significant impact on how well a child progresses with their communication, as well as how they regard us as a communicative partner. It may be helpful to use some ABA techniques to quantify some of our clinical instincts and shape behavior toward something more appropriate.
Use of Objective Assessments and Data Collection: Throughout the literature, ABA is described as being “all about the data.” However, as SLPs, we also are required to demonstrate the effectiveness of our treatments. One way that we do this is by the collection of various kinds of data that allow us to quantify various aspects of speech/language/communication. If we never collected data, we would not be able to say that a child is actually making progress. We would not be able to update or modify goals, or know when a child is ready to be discharged. Our profession is also becoming much more aware of the need to be steeped in evidence based practice.
Mr. Vedora makes the point that ABA is the only treatment program to have an empirical basis. While I can appreciate his thought, I find it does not fully express this issue. As an SLP, I am ethically bound to provide only those services that are safe, and that have some reasonable expectation of achieving the stated goal. I am required to maintain certification and licensure which both have requirements in continuing education, and staying current with the latest in research and new developments in the field. While ABA does seem to have some scientific support, especially when compared to some of the more “trendy” therapies offered, there is much more work to be done for both our professions in solidifying our empirical basis.
In my experience, I find that my issues with ABA go more to its implementation than its philosophical basis. My primary concerns are outlined below.
Team Communication Issues: One of Mr. Vedora’s primary points is that ABA educators are but “one member of a team.” In my experience, ABA often joins the team of professionals who have been working hard with a family, sometimes for months, and preparing for the eventuality of an ASD diagnosis. As team members, we have seen the parents and the child through some of their most difficult moments. When ABA is prescribed by a medical facility, they often come in and do their own assessment of the child. Again in my experience, they often do so without consulting the team that is in place. I have had several instances where an ABA person has said to a parent, “Now we are going to set up your communication program.” Not only does this undermine my professional credibility with the family as an SLP with extensive training, but it undermines the value of what has been provided to date. In these situations, parents are often scared, angry and grieving. They are seeking fast answers and quick fixes. They are often questioning whether they could have done things differently or should have. When a new person comes on the scene and basically wipes out months of work with a parent and sets themselves up as THE communication person, it is bound to cause confusion and impair team focus. Further, as it relates to scope of practice, SLPs are the only discipline licensed to provide services related to speech, language and communication skills.
Selection of goals: If the focus of ABA is to focus primarily on how we teach, rather than what is taught, it would make sense for the ABA team to come in and find out what goals are being addressed, and how the principles of ABA could support the child in achieving them. However, ABA typically sets up their own comprehensive curriculum, without regard to the cognitive load already on the child, and attempts to teach a whole new skill set while they are already struggling with their developmental therapies. While some aspects of speech and language lend themselves to discrete trial teaching, many of them do not. These children require input from qualified SLPs who are able to define functional and appropriate communication goals. Having ABA carry over these goals, rather than simply setting their own, provides consistency and helps children learn these skills faster, due to the number of hours per week they receive ABA. Further, having the mutual support of ABA would help reduce the impression that parents often get that ABA is somehow superior to ST/OT/PT because it can be received in greater quantity.
In my experience, the initial goals that are set for these children seem random and non-functional. The staff who are implementing the plan frequently cannot explain why they are doing a particular program, or how it will relate back to a more functional skill. One example I often see in the beginning stages is a goal for the child to tap their head. While I can understand that increasing imitation skills is a vital skill, I rarely see it go beyond this. Why not put a brush in their hand and teach them to brush their hair? It has also been my experience that some goals are not developmentally appropriate for a child, given their level of receptive language and/or cognitive development. Recently, I was working with a child with severe delays. He was receiving ABA services. The supervising clinician came in to do a site visit. It was his opinion that this child needed a way to request a break. He put a plan in place that changed the meaning of one sign that this child had mastered. He became so confused about how to request a break, and when it was acceptable to do so, that he significantly increased his self-injurious behavior. This program confused his fragile and emerging language system. This unfortunate series of events might have been avoided if there had been some discussion between this ABA clinician and myself, so that the child could benefit from both our skills and expertise.
Training and Education of Staff: While ABA supervisors are required to be Master’s level, many of the people charged with implementing those programs are younger, less experienced clinicians with a wide diversity in training and education about child development, language development and working with children. They are not able to change programs without their supervisor’s approval, and there are often time lags between supervisory visits. Many times, I have also found that the paraprofessionals do not have enough experience with how to interpret a child’s response to an activity, or a solid enough foundation in speech-language and child development. While I do not dispute the value of discrete trials and data collection (the science of our work), a major part of my skill set as an SLP involves being able to interpret how a child responds to the task and adjust accordingly (the art of our work.) Being effective with children requires more than just a rigid plan, it requires flexibility and creativity to help facilitate a child to participate and learn.
As an example of this issue, I worked a few years ago with a child who had an ABA program for requesting help, particularly to get someone to open a door to get out of the room. He had experienced a recent significant surge in his expressive language. When he went to the door, he said “I can’t open the door. Open the door.” The staff who were working with him refused to acknowledge this because he did not use the single word “Help”, which was how his program was written. We had to have a team meeting to discuss why this was not appropriate. SLPs have a wealth of knowledge about how to advance expressive language skills, and could provide structure and sequence to the ABA staff in setting and achieving functional communication goals, and advancing the semantic, syntactic and social use of language. This is particularly true for those aspects of language that are more creative and flexible in nature.
Overuse of edible reinforcers: While it is important to find things that are motivating for a particular child, I have had difficulty with the frequent use of edible reinforcers to teach non-feeding skills. I will use an example to illustrate my point. Recently, a child receiving ABA services had a goal to rub his nose on command. Every time he rubbed his nose, he received a cookie. As a result, when he was hungry, he would go into the kitchen and rub his nose. How does this relate to functional communication? How does this facilitate the development of receptive language, cause-effect association or pragmatics? This child had made the association that rubbing his nose = I get a cookie. No one outside of his ABA teachers would be able to make this association, this actually decreasing his chances of having this “request” granted. In addition, I have found that children who have edible reinforcers in ABA are less motivated to work with other professionals who are not offering these rewards. As a result, the non-ABA sessions, which are critically important, tend to be less effective. This is not in the best interest of the child. Working as a team could help to strategize ways to reinforce compliance without setting up a situation where a child is less likely to attend in the absence of these kinds of rewards.
My purpose in writing this article is to extend the invitation to ABA to double their efforts to work with the team that is in place when you begin working with a child. Actively seek out the input of an SLP about communication, speech production and language skills. Don’t reinvent the wheel. Take what we have to offer and value what we provide. Also, help educate SLPs and other team members about what you are doing and WHY. How will this goal relate back to a more functional skill? How can we support you in your work? Let’s work together to help these children reach their maximum potential, rather than working at cross purposes.
Speech-Language Pathologists also have responsibilities in this equation. As a member of a team for a child with ASD, we need to educate ourselves about all the interventions available, including ABA. This process has shown me how many similarities there are in the philosophical basis of our professions. We need to also be proactive in educating parents about the two, and in asserting ourselves with ABA staff. We need to make sure that the goals put forth by ABA in the language and communication arenas are appropriate, functional and fit in with their overall communication plan. We must be sure that we are actively advocating for these children and their families, and fulfilling our role on the team.
References:
Kabot, Masi and Segal. (2003). “Advances in the Diagnosis and Treatment of Autism Spectrum Disorders. Professional Psychology: Research and Practice. Volume 34, number 1: pp. 26-33.
Maurice, Green and Luce, editors. (1996). Behavioral Intervention for Young Children with Autism. Pro-Ed.
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