After noticing developmental delays and behavioral impairments in their son, the parents of three-and-a-half-year-old Caucasian Jamie Smith decided to bring him in for a clinical evaluation. After a careful assessment of his symptoms, it is most fitting to diagnose Jamie with Autism Spectrum Disorder (ASD). His symptoms fit the Diagnostic and Statistical Manual, 5th edition (DSM-V) criteria for ASD more than any other disorder. Several forms of treatment have been proposed that should be conducted all at once for optimal results.
In accordance with the initial criteria for ASD, Jamie displays “highly restricted, fixated interests that are abnormal in intensity or focus” (American Psychiatric Association, 2013, p. 50) when it comes to his obsession with trains. He is abnormally interested in a collection of toy trains and brings them everywhere he goes. Instead of socializing with classmates during free time at school, he prefers to sit in a corner and read about trains. Also in accordance with the criteria for ASD, Jamie displays “restricted, repetitive patterns of behavior, interests, or activities”, specifically in the stereotyped and repetitive use of objects, speech, and motor movements (APA, 2013, p. 50). His repetitive use of objects is shown when he prefers to line his trains up repeatedly instead of pushing them. His repetitive use of speech is shown when he repeats what his parents say instead of having a back and forth conversation; this is a common symptom in ASD known as echolalia (APA, 2013).
Lastly, his repetitive use of motor movements is displayed through repeatedly flapping his arms when he is excited. Another aspect of criteria that Jamie meets is “insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior” (APA, 2013, p.50). When Mrs. Smith asks Jamie to put his trains away, he throws a tantrum. Mrs. Smith allows Jamie to sleep with his trains because it is the only way he will be able to fall asleep without difficulty. He also has a hard time transitioning from one activity to another and becomes very upset when the daily schedule is changed. Jamie’s behavior is in accordance with another section of criteria which displays “persistent deficits in social communication and social interaction across contexts”(APA, 2013, p. 50). Mrs. Smith has noticed that he does not consistently make eye contact with her and rarely returns her smiles. Jamie’s symptoms are present in his early childhood and limit and impair everyday functioning. Since all of Jamie’s symptoms meet the criteria for ASD, it is the best and most appropriate diagnosis.
Another possible diagnosis would be an intellectual disability. The criteria are somewhat similar: deficits in intellectual functioning—“reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience”—confirmed by clinical evaluation and individualized standard IQ testing; deficits in functioning that “significantly hamper conforming to developmental and sociocultural standards for the individual’s independence and ability to meet their social responsibility” (APA, 2013, p. 33). While Jamie could have an intellectual disability, some of his symptoms such as ritualized and repetitive behavior and highly fixated interests only fall under ASD and are therefore better explained by that diagnosis.
The chosen diagnosis or alternative diagnosis should be further assessed in order to confirm/support or rule them out. Developmental screening is one recommendation for this. Developmental screening is a short test to tell if children are acquiring fundamental skills when they should, or if they might have delays (Lord et al., 2006). During this screening, the doctor may ask the parent some questions or talk with the child to see how they behave, learn, move, and speak. A delay in any of these areas could be a sign of a problem. It is important for doctors to perform this screening for all children with potential developmental delays, but especially to monitor those who are at a higher risk for these developmental issues due to low birthweight, preterm birth, or having a brother or sister with ASD (Lord et al., 2006). A second step that can be taken to further assess a diagnosis is through a “Comprehensive Diagnostic Evaluation”. This assessment is a thorough review that may include looking at the child’s development and behavior and interviewing the parents. It may also include neurological testing, genetic testing, hearing and vision screening, and other medical testing (Lord et al., 2006).
Nationally, “147 per 10,000 children are diagnosed with autism spectrum disorders by 8 years of age” (Becerra et al., 2014, p. 64). As a three-and-a-half-year-old Caucasian boy, there are some differences in prevalence based on demographics specific to Jamie. For example, “boys were 4 times more likely to be diagnosed than girls (1 in 37 versus 1 in 151) in 2014” (Becerra et al., 2014, p. 63). Research also provides evidence to show that children of US African American, foreign-born Central/South American, and US-born Hispanic mothers were at “higher risk of exhibiting an ASD phenotype with both severe emotional outbursts and impaired expressive language than children of US-born whites” (Becerra et al., 2014, p. 63). However, ASD prevalence is reported to be highest among white children, possibly because they are more likely to be diagnosed (Becerra et al., 2014). In terms of age, in one study, “4-year-old ASD prevalence was 13.4 per 1000, which was 30% lower than 8-year-old ASD prevalence” (Christensen, 2016, p. 2). Overall, many factors contribute to the prevalence and epidemiology of ASD.
Autism Spectrum Disorder is a complex genetic disorder in which disturbances in a myriad of processes and pathways are prevalent (Dietert, Dietert, Dewitt, 2010). For example, there may be rare mutations, CNVs, and epigenetic dysregulation. There may also be abnormalities in brain development, specifically in the cerebellum, medial temporal lobe, and associated limbic structures. A “broader Autism phenotype” may be present as well; this is when family members show minor impairments in social, communicative and repetitive behaviors. A variety of prenatal and postnatal factors may contribute to environmental risk for Autism.
These include maternal and/or paternal age, maternal use of prescription or non-prescription drugs, toxic environmental exposures such as heavy metals and pesticides, maternal illness and poor diet, Toxemia, viral infection, and preterm birth (Dietert, Dietert, Dewitt, 2010). While there are not many social and psychological causes for ASD, having the disorder might make symptoms worse through social isolation and victimization. Children with ASD may be at a higher risk for bullying and peer victimization than normally developing children due to their behavioral impairments and socio-communicative difficulties. Constant peer victimization has been related to many mental health problems among children with ASD; children who endured high rates of bullying were rated by their parents as having “higher levels of anxiety, hyperactivity, self-injurious and stereotypic behaviors, and oversensitivity than children who experienced no victimization or experienced low levels of victimization” (Cappadocia, Weiss, Pepler, 2012, p. 267). Similarly, children who were victimized were 5 times more likely to have higher levels of “child communications difficulties”.
All of these risk factors and causes relate to Jamie’s case in a couple of ways. Because Jamie has a reported family member labeled as “socially awkward with odd behaviors”, the “broader Autism phenotype” may have played a role in his development of the disorder. We also do not have enough knowledge about Jamie’s family to know if there may be more links to the phenotype. We should also acquire more knowledge about his mother’s pregnancy to understand if any prenatal and/or postnatal factors were involved.
I have proposed a treatment plan that covers multiple settings and targets many different symptoms. Firstly, parent-implemented intervention (PII) should be involved. This treatment allows parents to provide individualized intervention to their child in order to improve their skills and/or to reduce negative behaviors. Through PII, parents learn to deliver interventions at home through a structured training program (Wong et al., 2015, p. 1959). This will provide Jamie’s parents with a better understanding of his disorder and how to deal with it most effectively. Parent training is important for achieving generalized results. This treatment will also be helpful in preventing the parents from making great allowances in order to stop difficult behavior. Instead, they will have effective methods of parenting.
Another effective method of treatment for Jamie is the reinforcement method (R+). Reinforcement is an activity, event, or other situation which occurs “after a learner engages in a desired behavior that leads to the increased occurrence of the behavior in the future” (Wong et al., 2015, p. 1966). Reinforcing positive and desired behavior will decrease Jamie’s difficult and negative behavior. Reinforcing toilet training to stop him from using pull-ups as well as reinforcing listening to his mother when she tells him to put the trains away without throwing a tantrum are just a few examples of how this treatment will help Jamie.
A third treatment is necessary for improving Jamie’s symptoms. Peer-mediated instruction and intervention (PMII) are when normally developing children interact with and help ASD youth to acquire new communication and behavior skills by “increasing social and learning opportunities within natural environments”. In this treatment, teachers and service providers teach peer classmates strategies that will help them engage with children with ASD in “positive and extended social interactions in both teacher-directed and learner-directed situations” (Wong et al., 2015, p. 1959). This treatment will help Jamie to interact with his classmates better and more frequently during class time and free time.
While these three treatments are separate, they come together to create a holistic treatment approach that falls in line with ABA, or applied behavioral analysis. ABA follows general guidelines to help children with autism: “intervention should be started at the earliest possible age, intervention must be intensive, parent training and support are critical, intervention should focus on social and communication domains, treatment should be systematic, built upon individualized goals, and lastly, effective intervention must emphasize generalization” (Foxx, 2008, p. 825). ABA features empirically supported methods along with an individualized and comprehensive approach.
ABA is applied consistently through the use of programs to correct maladaptive behavior or to teach a new skill along with training everyone who works with the child. Generalization of treatment is only possible if parents and therapists are trained to implement the programs in all settings and situations (Foxx, 2008, p. 828). These multiple treatments should be conducted consistently and intensely, meaning that all forms of treatment should be happening around the same time. ABA emphasizes the importance of generalization in ASD treatment through “high levels of consistency, repeated and consistent presentations of material and individually selected and strategically used motivators” to maintain a positive and effective treatment environment. Therefore, treatments should be started at the same time.
PROTECTIVE FACTORS AND BARRIERS
Jamie has certain strengths that I believe will help him to meet his goals during treatment. His strong interest and excitement for trains will be able to help guide him through treatment and keep him focused in times of need. A lot of exercises and processes to help him may be facilitated through his interest in trains. However, there are a few potential barriers to achieving these treatments that may affect Jamie’s case. There are five themes related to barriers to treatment in ASD: “education, access, lack of parent credibility/voice, and parental fear of social stigma associated with an ASD diagnosis” (Elder, Brasher, Alexander, 2016, p. 414). This could mean that Jamie’s family may not have enough money for treatment, no access to treatment centers, no education on the effects of ASD on family, and/or many more factors that may impair effective treatment. We would have to get more information on Jamie and his family to understand the potential barriers that he may face.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. Arlington, VA: American Psychiatric Publishing.
Baio, J., Wiggins, L., Christensen, D.L., et al (2018). Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years — Autism and Developmental Disabilities Monitoring Network. Surveillance Summaries, 67(6), pages 1-23. http://dx.doi.org/10.15585/mmwr.ss6706a1.
Becerra, T. A., Von Ehrenstein, O. S., Heck, J. E., et al (2014). Autism spectrum disorders and race, ethnicity, and nativity: a population-based study. Pediatrics, 134(1), pages 63-71. https://doi.org/10.1542/peds.2013-3928
Cappadocia, M. C., Weiss, J. A., & Pepler, D. (2012). Bullying experiences among children and youth with autism spectrum disorders. Journal of autism and developmental disorders, 42(2), pages 266-277. https://doi.org/10.1007/s10803-011-1241-x
Christensen, D. L., Bilder, D. A., Zahorodny, W., et al (2016). Prevalence and characteristics of autism spectrum disorder among 4-year-old children in the autism and developmental disabilities monitoring network. Journal of Developmental & Behavioral Pediatrics, 37(1), pages 1-8.
Dietert, R. R., Dietert, J. M., & Dewitt, J. C. (2010). Environmental risk factors for autism. Emerging health threats journal, 4(7111), pages 1-11. doi:10.3402/ehtj.v4i0.7111
Elder, J., Brasher, S., & Alexander, B. (2016). Identifying the Barriers to Early Diagnosis and Treatment in Underserved Individuals with Autism Spectrum Disorders (ASD) and Their Families. Issues in Mental Health Nursing, 37(6), pages 412-420. https://doi.org/10.3109/01612840.2016.1153174
Lord, C., Risi, S., DiLavore, P.S., Shulman, C., Thurm, A., & Pickles, A. (2006). Autism From 2 to 9 Years of Age. Arch Gen Psychiatry, 63(6), pages 694–701. doi:10.1001/archpsyc.63.6.694
Matson, J. L., Williams, L. W. (2013). Differential diagnosis and comorbidity: Distinguishing autism from other mental health issues. Neuropsychiatry, 3(2), pages 233–243. http://www.jneuropsychiatry.org/peer-review/differential-diagnosis-and-comorbidity-distinguishing-autism-from-other-mental-health-issues-neuropsychiatry.pdf
Wong, C., Odom, S.L., Hume, K.A., et al (2015). Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review. Journal of autism and developmental disorders, 45(7), pages 1951-1966. https://doi.org/10.1007/s10803-014-2351-z
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