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Pervasive Developmental Disabilities with a focus on Asperger’s DisorderLynne CoxUniversity of CalgaryIntroductionAccording to the American Psychiatric Association (2000), Asperger’s Disorder (AD) is a pervasive developmental disorder (PDD) associated with substantial and persistent impairments in social interactions and the development of restricted, repetitive patterns of behaviour, interests and activities. Those with Asperger’s Disorder more likely have average or above average of intelligence with a high level of vocabulary. The disorder is a neurobiological disorder that falls under the umbrella term of autism spectrum disorder. It is important to understand autism as a “spectrum” disorder, as there is a wide range of intensity, symptoms and behaviours, and types of disorders that fall within the autism spectrum. At one end of the spectrum, a child may be non-verbal with asocial behaviour, as in a child having been diagnosed with “classic” autism, or on the other end of the spectrum a child may be high-functioning with poor socials skills and narrow interest, as in a child having been diagnosed with Asperger’s Disorder. Autistic Disorder, Asperger’s Disorder, Childhood Disintegrative Disorder, Rett Syndrome and Pervasive Developmental Disorder-Not otherwise Specified (PDD-NOS) are all types of autism spectrum disorders included in the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV-TR). This paper will provide a brief overview of the research, theory and neuropsychological underpinnings and intervention strategies of Asperger’s Disorder. Implementation of Kristi Upah and David Tilly’s 12 Steps Best Practice Intervention will be used in a case study as social skill interventions are developed for a student with Asperger’s Disorder. The term ‘Asperger’s syndrome’ is based on work by a paediatrician by the name of Hans Asperger. In 1944, Asperger was intrigued with the similar personality characteristics and behaviours of a group of boys with normal intelligence and normal language development but showed autistic like behaviours and inabilities in communication and social skills (Attwood, 2006). Children with Asperger’s Disorder usually have a history of developmental delays in motor skills such as pedaling a bike, catching a ball, or climbing outdoor play equipment and have are often awkward and poorly coordinated with a walk that can appear either stilted or bouncy (Attwood, 2006).EtiologyAlthough Autism Spectrum Disorders are understood to be a brain-based biological disorder, no clear universal cause has been revealed (McPartland & Volkmar, 2009). The most consistent finding in Autism Spectrum Disorders reflect a rapid brain growth in early childhood, leading to increased brain volume that normalizes in mid-childhood, resulting in a relatively small corpus callosum (McPartland & Volkmar, 2009). “Functional imaging has revealed abnormalities in brain activity associated with social information processing and social cognition as well as problems with functional connectivity among separate brain regions” (McPartland & Volkmar, 2009, p. 3). “Studies of Asperger’s Disorder genetics have demonstrated abnormality of functional integration of the amygdala and parahippocampal gyrus, and structural abnormalities of the inferior temporal gyrus entorhinal cortex and rostral fusiform gyrus” (Woodbury-Smith & Volkmar, 2008, p.6).The vast Neuropsychological literature on autism narrows individuals with AD into four areas pertaining to the limbic system hypothesis, the theory of mind, the executive function hypothesis, and the weak central coherence hypothesis (Woodbury-Smith & Volkmar, 2008).Joseph’s study (as cited in Tonn & Obrzut, 2005), suggests the limbic system hypothesis links the social and communication deficits to the medial temporal and limbic brain structures. More research investigating the role of the limbic system in the development of autism must proceed as it is plausible that abnormalities to the limbic system may contribute to the amnesic deficits seen in persons with autism (Tonn & Obrzut, 2005). The theory of mind hypothesis refers to the inability to take on the perspective of others’ mental states (Tonn & Obrzut, 2005). The child with AD does not recognise or understand the cues that indicate the thoughts or feelings of the other person at a level expected for someone that age (Attwood, 2006). Joseph, (as cited in Tonn & Obrzut) proposes research suggests that persons with autism have deficits in both theory of mind and executive functioning, proposing that executive dysfunction is the primary deficit, which in turn, directly affects performance on theory of mind tasks. The Executive functioning hypothesis views autism as deficits in executive control over behaviour and involves operations such as working memory, planning, inhibition of responses, as well as the maintenance and shifting of mental set. The weak central coherence theory suggests that individuals with autism pay more attention to parts rather than wholes. The theory is more concerned with the restricted and repetitive features of the disorder and addresses the savant abilities, such as, calendar and prime number calculation skills, or superior music or drawing abilities which are sometimes seen in autistic individuals (Tonn & Obrzut, 2005).Intervention StrategiesAlthough there is no single best treatment package most professionals agree interventions use strengths (e.g., cognitive or memory skills) to compensate for areas of weakness while establishing environmental supports to facilitate learning and socialization. Intervention programs must be developed according to individual needs and based on assessment. The programs should address basic social and communication skills, adaptive functioning, and academic or vocational skills (McPartland & Volkmar, 2009)The child with AD needs to be directly taught various social skills (recognition, comprehension, and application), in a one to one or small group setting. Social stories and social scripts will provide the child with visual information and strategies that help in their understanding of various social situations. Role play and video-taping of appropriate and inappropriate behaviours are helpful for the child to identify appropriate behaviours for social situations.Cognitive behaviour or talk therapy is used to help children manage their emotions, repetitive behaviours, and obsessions. Sensory processing intervention strategies; such as deep pressure, rhythmic vestibular stimulation proprioceptive stimulation, sensory breaks and a sensory diet are some of the strategies used to help the child with AD sustain focus.Successful programs target the child’s interests, offer a predictable schedule, teach tasks as a series of simple steps, actively engages the child’s attention in highly structured activities and provides regular reinforcement of behaviour. Diagnostic MethodsCurrently the diagnostic approach is to use clinical judgment combined with a combination of the autism diagnostic interview revised (ADI-R) and autism diagnostic observations scale (ADOS). Both of these assessments require training in administration and both have algorithms for ICD-10 and DSM-IV diagnoses of autism (Woodbury-Smith & Volkmar, 2008).Case StudyChildren with Asperger’s Disorder can be isolated because of their poor social skills and narrow interests. Although children with Asperger’s Disorder are typically motivated to interact with others, they often find themselves socially isolated because their communication style is often formal and may take the form of an in-depth monologue about a topic of special interest regardless of whether their interlocutor is interested or not (Woodbury-Smith & Volkmar, 2008). Stacey (actual name changed), is a 13 year old girl who currently lives with her father. Custody is shared between both parents, but a 600 km distance between parents makes it difficult for Stacey to commute between each parent, so Stacey spends the majority of her time with her father. She spends time with her mother when possible (holidays), but communicates by phone on a regular basis. Both parents describe their relationship as “relatively stable”. Stacey is an only child.Stacey attends grade eight at a high school with approximately 420 students. She was diagnosed with Asperger’s Disorder, Delayed Visual-Motor Integration and Reading Mathematics Disorders at the age of eight. An updated psychological assessment completed a year ago, recommends further inquiry into Clinical Anxiety and Depression.The school based team, including the school psychologist, and Stacey’s father see Stacey having significant difficulties across a broad range of areas; one being in social communication. Implementation of Kristi Upah and David Tilly’s 12 steps best practice intervention will be used to design, implement and evaluate quality interventions for the case study. The 12 indicators will be presented within the four stages of behaviour consultation: problem identification, problem analysis, plan implementation, and problem evaluation (Upah & Tilly, 2002).Problem IdentificationBehavioural DefinitionDifficulty with social interaction means that Stacey stands too close, makes poor eye contact, speaks in a monotone voice and lacks any form of emotional response while interacting with peers during class, breaks between class and during lunch. Stacey comes into student services every day to work in the cafeteria for work experience. She works with the same two peers. Both of these co-workers continue to request to work at different times than Stacey, as they find it difficult to work with her. Both peers have verbalized their frustration with Stacey saying she stands too close, speaks too loud and does not comply when requested to work at the opposite end of the counter. When Stacey is given positive feedback with an assignment, or experiences success with a play in basketball, she will respond with a smile and comment on how well she did. If directed to take one step back, Stacey will comply without question. Baseline DataA checklist will be used before intervention strategies are implemented to measure the number of times the target behaviour occurs while Stacey is working in the cafeteria each day during the 30 minute block of time for a period of two weeks. The descriptors on the checklist will be clear, specific and observable. For example: 1) Tally each time Stacey moves away from her end of the counter while serving students during the entire 20 minutes of serving customers. 2) Tally each time Stacey’s work experience supervisor asks Stacey to lower her voice during the 45 minute period of work experience. 3) Tally each time Stacey’s peers request to work at a different time than Stacey. This checklist will be completed by the education assistant who will be observing during the data collecting.Videotaping in the cafeteria will take place during the two week data gathering. This will be used to give feedback to Stacey before and after intervention strategies.Problem ValidationStacey’s current level of performance will be compared to her peers. The same data collecting checklist will be used to collect data for Stacey’s peers during the work experience opportunity. This will identify the difference between behaviour expected during the work experience opportunity and what is actually occurring. Comparing Stacey’s performance to her peers will identify a range of typical behaviour performance. If at the end of the two week data gathering the school psychologist and the problem solving team find a discrepancy between Stacey’s social interaction with her peers and the performance standard and if this discrepancy is large enough to warrant intervention, then the problem is validated then the next step should be implemented (Upah & Tilly, 2002).Problem AnalysisProblem Analysis StepsWhen looking at problem analysis, the team members are identifying why the problem is occurring. Data is collected in the four domains of instruction, curriculum, environment, and the learner.A file review and interviews with Stacey’s father, teachers, school counsellor, other relevant staff and an examination of the latest behaviour and assessments, indicate that Stacey is experiencing significant learning problems and severe academic delays. She needs assistance in developing some specific strategies and routines to assist her in improving her attention and concentration skills and in enhancing her working memory. Stacey should repeat back instruction to ensure that she understands what it is that she is expected of her. Stacey needs to participate in social activities with her age peers in both the school and community environments. She should be given opportunity to participate in a social skills group with her age peers that focuses on areas such as initiating and maintaining friendships, dealing appropriately with conflict, and interpreting social cues including facial expressions. Teaching her some relaxation techniques and strategies to manage her anxiety would be beneficial. Stacey does not want to appear different from her age peers; therefore any interventions presented will need to minimize her sense of being different.HypothesisStacey stands too close, makes poor eye contact, speaks in a monotone voice and lacks any form of emotional response while interacting with peers during work experience, because she is unable to read social cues and body language and forgets the expectations of the job from day to day. If Stacey is provided with the opportunity to learn the unwritten rules of socialization and communication and is provided with a visual reference for work expectations, she will demonstrate increased understanding of communication used by others; such as gestures, eye contact and tone of voice and will need less reminders social and work expectations. If needed, a functional Behavioral Assessment completed by the school based team will provide further details as to why Stacey has difficulty with social interaction and how this behavior is related to the environment.Plan ImplementationGoal SettingAfter 8 weeks of intervention, while on work experience and completing prep work and serving customers in the cafeteria, Stacey will demonstrate increased social communication skills as measured by the data collecting checklist originally used to identify problem validation. She will use a proper tone of voice and volume as measured by predetermined rubric criteria with 90% accuracy given role-playing and situational cues.Intervention Plan DevelopmentThe intervention plan ensures the school psychologist and all other parties involved share the same understanding of the procedures and intervention strategies that will be used (Upah & Tilly, 2002).Stacey will participate in a social skills group for one hour each day for a period of 8 weeks. Programs used in the social skills training group will be based on empirical evidence with focused instruction on addressing conversational Skills. The Direct teaching of social rules or conventions will help guide Stacey in her interactions with peers. If Stacey is going to learn the unwritten rules of socialization and communication, the approach must be clear and repetitive. The lessons will include teaching how to greet somebody, how to initiate a conversation, taking turns in a conversation, maintaining appropriate eye contact, and space awareness. Role plays, drama activities, video modeling, social stories, Model Me Kids videos and research based social skills training curriculum will be used as intervention strategies.During the problem analysis step it was identified that Stacey needs assistance in developing some specific strategies and routines to assist her in improving her attention and concentration skills and in enhancing her working memory. A step by step visual reminder of expectations during work experience will be placed in a strategic place behind the counter in the cafeteria which will remind Stacey of specific jobs she is to complete and the social rules she is to follow.Measurement StrategyTo allow accurate comparisons of data collected, the measurement strategy used will be the same checklist used to collect the baseline data. The student support worker will collect data starting beginning week five of the eight week intervention plan. The original descriptors on the checklist will be used. The data will be collected on a daily basis for the last four weeks of the intervention plan.Decision Making PlanData will be summarized by the case manager and share with the social skills teacher at the end of each week. If data shows a decrease in identified behaviour, the plan will continue as implemented. If the target behaviour is staying the same or increasing, the plan will be modified.Program EvaluationProgress MonitoringData from the checklists will be graphed and used as a visual to monitor any trends in the problem behaviour. Sharing this data with teachers, parents, and Stacey will validate the time spent in the social skills group and show how the behaviour change is functionally related to the intervention being implemented (Upah & Tilly, 2002).Formative EvaluationUsing Kazdin’s (1982) visual analysis criteria the data collected each day and weekly summarization will help guide the intervention strategies. When analysing the data, the rate of performance of targeted behaviour, performance trend and time frame will all be observed. If the data is flat, or variable, the school psychologist and other problem-solving team members may need to look at intervention strategies and adapt and modify where needed (Upah & Tilly, 2002).Treatment IntegrityTo ensure treatment integrity the case manager will monitor the social skills training group lesson plans, and will make random observations of lessons each week. The social skills training teacher will provide lesson plans for each day, which will set out the goals of the lesson, how each goal will be met, and assessment strategies that will be used. The case manager will share a summary of the integrity checks with the school psychologist.Summative EvaluationAfter the eight week time frame and the intervention are completed, a summative evaluation will be written. Data collected will support an answer to the hypotheses that was established at the beginning of the intervention.ConclusionAutism Spectrum Disorders are understood to be a brain-based biological disorder, with a general consensus that children diagnosed with AD usually have relatively intact intellectual and language functioning, accompanied by the impairments in reciprocal social interaction that are associated with autism (Mash & Barkley, 2003). Children with AD exhibit significant communicative difficulties increased motor clumsiness, as well as other behaviour characteristics that may be appropriate in content but unusual in their intensity. Upah and Tilly’s 12 quality indicator model assists in guiding intervention strategies will allow the school psychologist and problem solving team to design, implement and evaluate quality intervention. There is no known treatment that has any effect on the basic impairments underlying AD, but with intervention programs developed according to individual needs and based on assessment children with AD can learn to cope with their disability, but may still find social situations and personal relationships challenging.ReferencesAmerican Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders(4th ed., rev.). Washington, DC: Author.Attwood, T. (2005). Asperger’s Disorder. In Encyclopaedia of Cognitive Behaviour Therapy Feligoise S., Nezu, A.M. (pp 49-52).Attwood, T. (2006). Asperger’s Syndrome. Learning Disability Review, 11(4), 3-11.Mash, E.J., & Barkley, R.A. (2003). Child psychopathology (2nd ed.). New York.NY: Guilford Press.McPartland, J., & Volkmar, F. (2009) Current Clinical Practice in Asperger Disorder. Psychiatric Times, 25(11) 52-56.Tonn, R., & Obrzut, J. (2005) The Neuropsychological Perspective on Autism. JournalOf Developmental and Physical Disabilities, 17 (4) 409-418.Upah, K. & Tilly, D.W. (2002). Best practices in designing, implementing, and evaluating quality interventions. In Thomas, A. & Grimes, J. (Eds.), Best practices in school psychology (pp. 483-501). Bethesda, MD: NASP Publications.Woodbury-Smith, M., & Volkmar, F. (2009) Asperger Syndrome. European Child & Adolescent Psychiatry 18, 2-7. ................
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