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Autism – A brief historic perspective

November 21, 2016 Leave a comment

History is in the past but can help place things in perspective. While autism diagnosis strikes most parents from the blue, suddenly from no where, history says it has been around and recognized atleast 5-6 decades ago ( probably even earlier??). I will present some key milestones, the early blunders in understanding and current evolving understanding.

Retrospectively viewed, the earliest known description of symptoms of autism could possibly relate to Victor, a French feral child found in 1800 and believed to have lived alone in the woods for nearly the first 12 years of his life. Despite a young physician’s (Itard) intense efforts to teach him he only learned to speak two words but did make progress in his behavior towards other people. One day when the housekeeper was crying in grief over loss of her husband, Victor is reported to have engaged in consoling behavior and Itard reported this as progress. In 1867, Henry Maudlsey is said to have described insanity in children and his descriptions are consistent with today’s ASD.

Eugene Bleuler (1911/1950), a Swiss psychiatrist coined the term autismus to describe idiosyncratic, self-centred thinking during his work on schizophrenia.
In 1943, Leo Kanner introduced the modern concept of autism while describing 11 children with “autistic disturbances of affective contact”. He not only used it to describe children who lived in their own world cut off from normal social intercourse but also proceeded to distinguish it from schizophrenia indicating a failure of development instead of regression. Children with autism were described as inflexible, preferring sameness and rigid. In the following years, Kanner proceeded to hypothesize that autism was influenced by parenting, a dearth of maternal warmth { and this shoes how even scientists who are dead right about certain things can be equally dead wrong about certain things) and that many such children were not motivated to perform though not retarded.

In 1944, Hans Asperger used the term autistic psychopathy, now referred to as Asperger’s disorder in DSM- IV- TR and his study became widely known only in 1991 when it was translated in English by Frith.

The DSM I manual first released in 1952, classified autistic-like features under Childhood Schizophrenia. In 1967 Bruno Bettelheim popularized the theory of “refrigerator mothers” as cause of autism amongst public and medical community ( Another example of a scientist being dead wrong leading to harm in society) . These have since been disproved in research literature (Mundy etal., 1986). In 1977 the first study of twins helped change the perceptions and look towards genetics for understanding ethology of autism.

In 1987, psychologist Ivar Lovaas presented his first study demonstrating that intensive intervention can help children with autism learn. In the same year, autistic disorder replaced “infantile autism” in the diagnostic manual. Dustin Hoffman, essayed the role of a Autistic Savant in the movie “Rain man” which raised public awareness of the disorder while at the same time creating a mis-perception that all autistic individuals have savant like qualities. In 1993, Catherine Maurice’s book “Let Me Hear Your Voice: A Family’s Triumph Over Autism” brought into public view the effectiveness of use of interventions based on the science of Applied Behavior Analysis. In the same year, Jim Sinclair, an autistic adult started a neuro-diversity movement and spoke at the international conference on autism.

MMR vaccine was proposed as a cause of Autism in a Lancet study of 1998 but it was debunked and retracted though the controversy it raised continues till today.

In 2007, the US Center for Disease Control and Prevention estimated prevalence of Autism at 1 in 150 recognizing it as assuming epidemic proportions . this had climbed to 1 in 68 by 2014 ( “ Autism Spectrum Disorder: Data and Statistics” , 2014). As the prevalence figures kept climbing geometrically some researchers started questioning the validity of the prevalence figures. Gernsbacher, Dawson & Goldsmith (2005) have argued that the diagnostic criteria have been diluted, particularly between DSM III (1980) and DSM 4 (1990)  and other statistical errors contribute to a misperception of an epidemic.
In 2013 , DSM V was released and it clubbed several separate diagnosis into one diagnosis of Autism Spectrum Disorders.

Research into the cause of ASD continues to be unsuccessful in pin pointing the cause however there are advances in interventions  that can help individuals with autism acquire new skills and lead a better adapted life.

A history of Applied Behavior Analysis and evidence based interventions could be the next blog topic.

 

 

References

Autism Spectrum Disorder, (2014). Retrieved April 10th,2014 from http://www.cdc.gov/ncbddd/autism/data.html

Autism: Rise of a disorder. Los Angeles Times 06 dec 2011, Data desk n. pag. Web. 10 Apr. 2014. .

Autism Timeline | Neurotypical | POV | PBS. (n.d.). Retrieved April 10, 2014, from http:/   /www.pbs.org/pov/neurotypical/autism-history-timeline.php#.U0aH8fmSySq

Gernsbacher, M. A., Dawson, M., & Goldsmith, H. H. (2005). Three Reasons Not to Believe in an Autism Epidemic. Current Directions in Psychological Science, 14(2), 55–58. http://doi.org/10.1111/j.0963-7214.2005.00334.x

Goldstein, S., Ozonoff, S., (2009), Historical perspective and overview. In S. Goldstein, J. A.   Naglieri & S. Ozonoff( Eds.,), Assessment of autism spectrum disorders (pp 1-13). New York, NY: Guilford Press

Wing, L., Potter, D.,  (2009), Historical perspective and overview. In S. Goldstein, J. A.   Naglieri & S. Ozonoff( Eds.,), The Epidemiology of Autism Spectrum Disorders: Is the prevalence rising?.  (pp 18-45). New York, NY: Guilford Press

Walsh, Neil, and Elisabeth Hurley. The Good and Bad Science of Autism. Autism West Midlands, UK. Web. 10 Apr 2014. <http://www.autismwestmidlands.org.uk/files/epub_goodbadscienceofautism(1).pdf>.

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Categories: Uncategorized

The art and science of generalization

November 8, 2016 Leave a comment

Note: The author is a Board Certified Behavior Analyst who works with Behavior Momentum India (www.behaviormomentum.com) . The views in the blogs are his own.I would like to thank a fellow Behavior Analyst,Dr. Geetika Agarwal, BCBA-D for her valuable comments and pointers on an earlier draft of this blog.

One of my  ‘aha’ moments came like this. I was teaching a boy on the autism spectrum to request (mand) information using ‘where’. Soon enough,he was asking “where are the crayons”, ” where is the scrabble box” and so on. One day, his mom came to observe his session, observed carefully, made notes and left after about 45 minutes. I was taking him around to play. He didn’t seemed very enthused about the play options and was looking a listless and a tad sad. A few more minutes later, he peered into my eyes and asked in a low sweet voice ” Sridhar, where is mummy? “. Aha…. generalization had happened and it was so functional and appropriate! We cannot always  assume that generalization will happen in due course. Rather, from the first instance of teaching any skill, generalization has to be planned for and programmed.

All of us generalize what we have learnt. Performing in practice tests to performing in a real exam, learning dining etiquette and using it in corporate dinner event, cracking jokes with friends to using humor in meetings , lectures or talks.. the examples are numerous. Generalization is important because the skill learnt in one setting needs to be used sometimes in vastly varying contexts.

Parents of children with autism and developmental disabilities are most concerned about this. We need generalization for sure.  If the child’s acquired skills do not generalize across people, different environments and across different contexts where they are meaningful the value of acquired skill is down to zero!  Like all good things , it needs to be planned for right from the beginning and when achieved  it needs to be balanced.  Over generalization or under generalization can be a problem  too. consider the following scenarios:

Image result for over generalization fallacyImage result for generalization

  1. Neeraj has learnt to wash hands independently but he does that only at home independently. In a restaurant or at a friends place, after a meal he may not proceed to wash his hands.
  2. Pranav sits and attends appropriately to task in the math class but not in the english class
  3. Keerthi a 3 year old girl has been taught to point at mummy and daddy when asked. However, when there were many visitors at home and someone asked her ‘where is daddy?’ she pointed to the nearest male – generalization without requisite discrimination?  Image result for multiple exemplar trainingA mom is not a girl? need for training with multiple examples

4.Rachel, a teenager  could fold her clothes and stack them up in her cupboard. One day, when mom tried to get her to help with folding towels and blankets at home and was surprised that Rachel could not fold blankets

5. Chris had learnt to answer questions about himself when his mom or his therapist asked. However, when was lost briefly in a mall and when people who wanted to help him asked for his parents name and phone numbers, he just sat down crying and was not able to answer questions about himself.

While it may not be possible to discuss this vast topic of generalization a look at some of the key principles and strategies behavior analysts use to program for generalization could help. Parents who see their children acquire skills in clinical setting  could focus on immediately generalizing those at home and in community settings. If there is a hurdle in generalization they should discuss it with the Behavior Analyst responsible for programming as they could plan and program for generalization better. Some strategies are discussed below:

a. It begins with target selection. Target only those behaviors and skills that will meet reinforcement in natural communities after the skill is acquired. For example, teaching to sing or play keyboard in a small group setting can generalize all the way to stage performances with potential to contact reinforcement from natural communities throughout life. Conversation skills, Social etiquette, play skills etc. too fall in such a category. A non example – would it be appropriate to teach penmanship to a child who does not read or recognize words yet?.

Image result for useless goals

need for meaningful targets

b. Teach Multiple examples or sufficient examples for every target : For instance if discriminating between clean versus dirty is being taught , multiple examples could be used  – a dirty cloth vs clean cloth, a dirty paper versus clean one, badly stained glass versus clean glass etc., all the time probing to see if generalization has occurred to other novel contexts. Teaching sufficient examples means teaching using as many examples as required until generalization to all possible variations occurs. For example teaching a child to pronounce 5, 6 or 10 words correctly with the “r” sound until he or she is able to pronounce all functional words with ‘r’ correctly.

Multiple examples of sharp:
Image result for sharp items  sharp-items

c. Teaching both context and response variations : To the question “how are you ?”different responses such as ” I am fine”, ” I am good” , ” great”, ” Ok”.. can be taught. Similarly the response “14 years” should be produced by the learner regardless of whether the question was ” How old are you? ” or it was ” whats your age”.

d. Teaching all possible situations – this involves teaching all examples that could covers all possible situations and varying responses – for example , teaching the use of every type of ATM machine in the neighborhood. This may not always be a feasible option, and nor may it be required in most scenarios.

5. Building familiarity in training setting – In the teaching setting it may be useful to introduce features of what will be out there in the natural setting where the skill has to be used. For instance, while teaching shopping skills in a dummy super market set up it may be useful to include shelves, ‘promotional signs, ‘pay here’ signs, trolleys etc., If you are teaching teaching dining with peers in a home setting with eventual goal of eating out in a restaurant, it will be useful to have cutlery, menu card, napkins and perhaps adult attending on the students and taking orders  like waiters would in a restaurant.

6.  Use some elements from teaching setting in generalization setting : For example a student who is used to a point system or a smiley reward system may benefit if the same is used in a generalization setting such as following etiquette rules in a restaurant or making a choice independently from a menu or being engaged appropriately in the back seat in a long journey. Yes, for some time, it may be a good idea to introduce rewards in the real life-generalized setting similar to the ones used during training.

7. Some children on the spectrum who have difficulties with responding consistently correctly to different people or in different locations will benefit from variations in teachers, positions, location of teaching, variety of tones , distractions being present etc.

8. Rule out dependence on inadvertent cues :  If a child performs well with one therapist but not with another, or with parent but not anyone else it is also important to see if the first therapist or parent is providing some subtle cues inadvertently which others do not provide. Behavior Analysts constantly strive to promote independence and will need to critically examine and completely fade out dependence on any type of prompts that may have emerged during training.

There are many other specific strategies but the above should provide an insight into some of the guiding principles for successful generalization. Much can be achieved by planning for generalization, conducting generalization probes before , during and after training on any skill ( “will he play the keyboard equally well in front of a small group of strangers? “, ” Will he whack the ball to the boundary line when playing in a larger field?”…) and planning and teaching taking into account variations in contexts and responses. Discrimination and generalization go hand in hand and training one would also require training on the other. That is a topic for another day.

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