Tri-Therapy(Body, Mind, Soul)
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As presented by Shamai Currim To the University of Bridgeport Thesis-in compliance with requirements for the MS in Education Final Draft: May 9, 2002 Introduction Autism, while characterized as a social and communicative disorder, occurs more often than one would hope. Since the 1960's there has been much research, and many methods of intervention. While we are speculating on causes, more and more children are being diagnosed. Researchers, writers, educators and parents are still in the search to reach these depth-protected humans. All of us have situations, experiences, and perceptions of ourselves that make us more or less than we really are. We have the ability to think, and to speak those thoughts. Some people with autism are stuck inside themselves, finding that their inner being is not what presents to the outer world. Those that have learned to communicate have been able to show us that there is hidden intelligence within each and every one of them. This paper makes an attempt at presenting an understanding of what autism is, how it relates to the ability to communicate, and the multitude of interventions available today. This paper does not attempt to show that one system works better than another. It is but a feeble attempt to present what is available to today's families, educators, and children with autism. Every child with a label of autism, just like every human being, has their own needs, and wants and desires. If we but give ourselves the chance to really listen to the needs of each child, then we will have achieved what teaching is really all about. What is Autism? Finding out what autism, or Autistic Spectrum Disorders (ASD) is can be quite an interesting journey. The diagnostic and Statistical Manual IV (DSM IV) categorizes ASD as a pervasive developmental disorder. A diagnosis is made when six or more items in three core areas: social interaction, communication, and patterns of behavior, interests, and activities are present. The items include:
The following characteristics were featured:
Rutter, in 1978 (1) added in the following criteria in relation to behavior before 5 years of age to define childhood autism:
Koegel reminds us that the lack of social-communicative gestures and utterances are one characteristic exhibited in almost all children with autism. For some it begins very early on, even in the first few months of life, when children do not engage in simple social behaviors (eye gaze, smiles, response to parents' attempts to prompt vocalizations and play interactions). Their learned vocabulary and language is often used instrumentally rather than socially. Pragmatic skills, such as initiating conversation and responding to the conversations of others, which requires appropriate turn taking, prosody, speech detail, perseveration, and attention during the conversation, may be lacking. If language emerges, it is primarily used for requests and desires. The incidence of autism has been estimated to be about 1 out of every 2,000 live births and is four to five times more common in males than females. Problems of communication are seen as the primary disability in autism. Koegel et al. have found that "when children are taught to engage in appropriate communicative behaviors, inappropriate behaviors such as aggression, self-injury, and certain types of self-stimulation decrease without special intervention". (Koegel, 1995,pp.3) "Most self-stimulatory behaviors appear to have little or not obvious social meaning to others, and appear to interfere with relationships, learning, and neurological development". (Koegel, 1995,pp3). When these behaviors are suppressed, spontaneous increases in academic responding and play are observed. It is now understood that when there are certain types of play and learning, certain stereotypic behaviors spontaneously decrease. Functionally equivalent replacement behaviors are now being taught, creating a shift in the belief systems of the past and focusing more on the communicative function of these behaviors. "Autism is characterized by problems of speech, language, and communication, including mutism, echolalia, and perseverative speech, difficulties with social interaction, stereotyped activity, a seeming concern for sameness or constancy of order, and a lack of response or unusual response to external events or actions." (Biklen 1993, pp.15). "The language behaviors associated with autism include delay in the development of language and atypical expressions of language." (Bilken 1993, pp.15). It has been believed that students labeled ASD who acquired speech did so by rote, without understanding abstract concepts (time, color, size, feeling). The repetitive echolalia, echoes without link, incorrect semantics, lacking in the flexibility of normal language form and flow, is believed to come from the limbic system rather than the more complex cortical control. For some children with autism, verbal language does not develop. "A number of authors have recently discussed core underlying problems of communication as the primary disability in autism." (Koegel 1995, pp2). Difficulties maintaining eye contact, gestural communication, protodeclarative pointing and joint attention are behaviors that prove to be early indicators of autism. "An expression of one's own and others' emotional states and feelings is a common goal of communication" (Fussell, pp1) which is lacking in the autistic individual. Wetherby (2) hypothesizes that people with autism may have insufficient cortical control of the limbic system, causing an incapability to control vocal signals that involve emotional of self-stimulatory reactions or responses, creating incessant questioning, preoccupation with specific topics and an inability to shift topics and a poor perception of listener needs. Physiological studies, using autopsies and magnetic resonance imaging, reveal anomalies in the limbic system and in the cerebellum, but not in the cortex. Potential Causes "Some possible causes and signs of autism that have been the focus of research include prenatal, perinatal, and neonatal complications, such as bleedings, pre- and post-maturity, severe infection during pregnancy, generalized edema, medication for more than one week during pregnancy, reduced Apgar scores, and congenital rubella". (Koegel, 1995,pp.4) This physiological data is still inconclusive even though neurological and neuroanatomical research has found atypical patterns of cerebral lateralization, differences in brain stem responses, abnormal EEG's, and cerebellar asymmetry in specific areas. Interpretation of these studies is complex and further studies are needed to elucidate these findings. Some neurochemical researchers have found differences in blood serotonin levels. The administration of fenflumamine as a means of reducing these levels has produced some positive changes in behavior. Through the opioid systems or beta-endorphins and changes in acetylcholine levels, or differences in vitamin metabolism, researchers are experimenting to find answers. The connection between vaccination and autistic behavior was first reported in DPT: A Shot in the Dark (Coulter & Fisher, 1985) fifteen years ago. There have been persistent reports by parents in the U.S., Canada and Europe that their children were healthy, bright and happy until they received one or more vaccines which resulted in autism, marked by chronic immune and neurological dysfunction, including repetitive and uncontrollable behavior. In 1999 a congressional hearing was held in the U.S. Congress. The media began to explore the medical controversy in print and broadcast reports. At the heart of the debate stand a few courageous physicians whose independent, multi-disciplinary approach to investigating the possible biological mechanisms of vaccine-induced autism is serving as a counterweight to the steadfast denials by infectious disease specialists and government health officials defending current mass vaccination policies. Parents of now grown vaccine injured children had warned pediatricians and Centers for Disease Control (CDC) officials in the 1980's that their once healthy, bright children had regressed mentally, emotionally and physically after reacting to DPT vaccine with fever, high pitched screaming (encephalitic cry), collapse/shock, and seizures, are grieving with a new generation of parents whose healthy, bright children suddenly regress after DPT/DTaP, MMR, hepatitis B, polio, Hib and chicken pox vaccinations. The refusal two decades ago by vaccine manufacturers, government health agencies and medical organizations to seriously investigate reports of vaccine-associated brain injury and immune system dysfunction, including autistic behaviors, is reaping tragic consequences today. Some doctors today, in a rejection of the unscientific a priori assumption that a child's mental, physical and emotional regression after vaccination is only coincidentally but not causally related to the vaccines given. They are calling for credible basic science research into the biological mechanism of vaccine adverse events to develop pathological profiles which will separate health problems caused by vaccines from those that are not; the development of screening techniques to identify children at genetic or other biological risk of developing vaccine-induced health problems; the institution of informed consent protections in vaccination laws; re-examination of vaccine licensing standards; and an end to one-size-fits-all vaccination policies. The U.S. government, the pharmaceutical industry and international corporate interests announced on March 2, 2000 the creation of a new multi-billion dollar alliance called the Millennium Vaccine Initiative (MVI) to vaccinate all of the world's children with existing and new vaccines, including those being targeted for accelerated development for AIDS, tuberculosis and malaria. According to the annual NIH Jordan Report, there are more than 200 vaccines in various research stages. Dozens are under consideration for childhood use. Even as the race to add new vaccines to the routine child vaccination schedule rushes forward, parents, whose children became autistic after receiving existing vaccines, are changing the direction of autism research and the vaccine safety debate. Communication Webster's Dictionary defines communication as the act of imparting, conferring, or delivering from one to another, an intercourse by words, letters, or messages. It includes the interchange of thoughts or opinions, knowledge or facts. It refers to holding and receiving information, signals or messages in any way. Assagioli (1963) tells that expression should be creative and should be part of a conception of a "psychological space" or field within which the creative process takes place. He reminds us that "every strong drive tends to express itself outwardly, in action, and when this is denied, inhibited or repressed, it seeks and may find indirect manifestation and a measure of satisfaction through some kind of creative expression". (Assagioli 1963,pp.2) He tells us that the next stage, that of gestation or elaboration, of growth and development, takes place in the unconscious, alternating with stages of conscious activity. The ensuing inspiration, or birth, can occur at very different stages of development, as evident in various animal species. "Sometimes the "creature" is complete and vital; in other cases it is still an immature fetus which needs further growth." (Assagioli 1963, pp3). Creation entails the work of developing, polishing, and putting into shape the more or less inchoate product that has emerged. In a study done by Carr and Durand (1985) it is noted that " inappropriate behavior may function as a form of communication." (Koegel 1995, pp178). Pragmatics needs to be looked at, as well, when dealing with difficulties with communication. Paralinguistic features and extralinguistic, or nonverbal features, are assessed at the utterance level. This involves intelligibility and prosody. This involves the assessment of language at the level that analyzes communicative intentions through changes in stress patterns, duration, intonation, pitch, and intensity levels. Extralinguistic, or nonverbal, involves the use of gestures and a variety of body movements that are non-verbal in nature and aid the communicative intent of an utterance. Hand movements demonstrating size during a conversation would be an example of giving additional communicative information to the listener. The use of paralinguistic aspects of language is important for both communicative intent and for maintenance of listener engagement. Linguistic intent assesses the utterance as well as previous and past utterances. These utterances need to occur in the context of social discourse, and considers the known, supposed, or presumed knowledge of the listener. Communicative intent classifies into requesting information, requesting action, responding to requests, stating or commenting, regulating conversational behaviors, and other performatives. It is dependent on the previous knowledge of the listener, and on both the previous and following utterances and/or actions of the communicative partner. It cannot be analyzed at the utterance level but on the discourse. Linguistic intent is supported or aided by paralinguistic and extralinguistic cues. Social competence assesses a broad area, which includes utterances and the social context. This level includes both verbal and nonverbal skills that speakers use during interactions. Speakers use a variety of skills to communicate which include:
Discourse regulation involving both verbal and nonverbal cues is necessary for fluent conversation, including the ability to monitor the speaker's messages and to provide feedback to the speaker concerning their effectiveness. Children learn at a very young age, from adult feedback, that increased specificity is desirable. Children gradually increase the effectiveness in social-communicative context through adult guidance. Communication of affect and emotions, and the expression of one's own and others' emotional states and feelings, are common goals of communication in both everyday and clinical settings. These emotional expressions play an important role in establishing and maintaining social relationships. Children with autism have difficulty interpreting affect and the emotional lack of social-communicative gestures and utterances. Any attempt to prompt vocalization or play interaction may be unattainable. "Even when language competence is achieved, pragmatic skills such as initiating conversation and responding to the conversation of others, appropriate turn-taking, prosody, speech detail, perseveration, and attention during conversation may be lacking. (Koegel 1995, pp2). Children with autism frequently speak in monotone, lacking appropriate paralinguistic features. They lack intensity, pitch, and intonation, and frequently have unusual stress and intonation patterns, as well as echolalic and self-stimulatory verbalization. They are usually lacking in hand and arm movements, facial expressions, and body posturing. Many times they do not give adequate attention to the communicative partner to be sufficiently able to participate in the dyadic interchange, perhaps because of their self-stimulation or because the communicative interaction is too difficult for them. Also, they may not have adequate language skills for self-expression as well as significant delays in utterances leading to an insufficient number and quality of interactions, with an end result of social isolation. Children with autism are usually violators of boundaries, and tend to display tantrums, aggression, and other avoidance, escape, or attention-seeking behaviors. It is believed that these difficulties are pathognomonic to the syndrome and can persist throughout life unless intervention is provided. While some people attempt to distinguish the language abnormalities of autism, Churchill (3) proposes that there are no qualitative distinctions between developmental aphasia and autism, and that they differ only by degree. Wing (4) reminds us to be aware of the continuum of autistic disorders. She regards social impairment as the core symptom. Children can be characterized by a triad of deficits in social recognition, social communication and social understanding. The range may be from no effort to initiate communication, to the use of language to achieve some end, such as obtaining an object. The mildest form of impairment would be subtle difficulties in recognizing the needs of conversational partners. Within this triad students would be defined by defective pragmatic aspects of language and problems with formal aspects of language (grammar, phonology) associated with the social impairments. Semantic-pragmatic disorders, delayed language development and evidence of comprehension problems would represent the child with autism. Interventions The Individuals with Disabilities Education Act (IDEA), most recently updated in 1997 (PL 101-476) has affirmed the right of all children to fully participate in the life of the community into which they were born (Brown et al., 1989). The fulfillment of this right, for children with autism, may require intensive intervention. For maximum effectiveness, such multiple interventions often require coordinated implementation well before a child's school years. A major goal of intervention is to achieve a typical life in the community of a child's birth. The presence of a significant language delay often complicates the realization of this goal. Many children with language delays depend on others for initiating communication and motivating social interaction which can lead to learned helplessness. Autistic spectrum disorders were traditionally managed with intense, early, and generalized educational, language, and behavioral interventions. Early research for children with autism who exhibited little or no functional language used the principles of reinforcement and punishment to eliminate psychotic speech and reinstate appropriate verbal behavior. This operant training technology focused on teaching verbal imitation. It was assumed that children learn to speak by attending to and repeating the speech of others and by being rewarded for approximations to adult speech. The environment was arranged so that all distractions were removed. A stimulus was presented and the child prompted with rewards for correct responses (eg.-edibles, stroking, exaggerated social approval, tokens, or other desired stimulus). These rewards were gradually delayed as the child showed improvement, in an attempt to strengthen the social consequences. Punishment (loud 'no's, slaps, attention withdrawal, other unpleasant consequences) followed incorrect responses. Prior to commencing with language treatment, children who exhibited aggressive, self-injurious, or disruptive behavior were given aversive stimulation (eg.-deprivation of lights, rewards, and the presence of others, time-out, physical punishment). The philosophy was that disruptive behaviors would interfere with teaching and subsequent learning. It was felt that language cannot be separated from any other operant behavior, therefore verbal behavior is subject to the same consequences. The child's use of verbal communication acquires strength and continues to be maintained when responses are frequently followed by reinforcement. Parents, from early on, are asked to reinforce behavior that is part of the desired final pattern. Researchers within this early theory conceptualized early phonemic behavior (consonants, vowels) as a form of imitation, without meaning. The students were taught to imitate the verbal utterances (phonemes) of others hoping that the language would conceptualize outside of its social context. It was felt that any nonverbal attempts to communicate were disruptive or interfering and the students were punished. The language sessions were highly controlled. The children exhibited a general lack of spontaneity and the language skills were not exhibited without prompting or generalized to other environments. Three teaching strategies have been adopted to educate children with autism. These strategies are stimulus generalization, response generalization, and maintenance. Some examples of this are: reducing the discriminability of the reinforcement schedules, delaying the reinforcer, teaching behaviors that are likely to be rewarded in the child's natural environment, teaching family members and teachers to provide ongoing intervention, fading items or people into the intervention setting, and establishing responses in the clinical setting that are likely to be used in the child's natural environment. Learning is a cumulative process, systematically building on prior knowledge. Early attempts to teach language that emphasized repetitive practice, controlled instructions, consistent and artificial reinforcers, and structured training environments did, in the end, actually retarded the efforts to achieve generalized intervention effects. An alternative to the historical approaches is naturalistic teaching. This procedure involves the use of naturally occurring opportunities to teach communication skills and is designed to focus on behaviors that are of immediate functional utility. Routinely available items and activities of reinforcing value are used as a consequence for the communicative behaviors. These newer programs evolved as attempts to solve problems of generalization and maintenance and resulted in increased motivation and responsivity. An emphasis on reciprocal interaction, the child's role as an active communicative partner led to a more socialized system. The shift from teacher prompt to child interest, from consistency to functionality more closely resemble the way typically developing children learn naturally to speak. These naturalistic interventions focused on functional language skills in a social context, or what has been coined milieu teaching. The Natural Language Paradigm (NLP) builds upon arranging the environment to increase opportunities to use language. The basic motivation is to gain access to desired items or privileges. These responses can later be expanded. First, teaching follows the child's choice, lead, or interest. There must be sustained attention to a target object. Structure can be taught during natural play interaction. The target language structure is presented in the context of the activity that the child is involved in. Koegel found that "Children with autism have also been shown to be more successful in learning initial words and language and to engage in longer periods of sustained conversational interaction when their interests are considered." (Koegel 1995, pp25) The interspersing of tasks mastered with new material must be varied. It is also important to teach multiple exemplars in natural environments to provide for generalization. Teaching occurs in the contexts where language is to be used. The cues are similar to those the child will encounter in everyday interaction. The child's language production is then prompted, providing an opportunity for the consequences for child response to be directly associated with the form. Rewards for speech attempts provide for more rapid and consistent progress. Emphasis is placed on turn taking, with an ongoing interaction between the teacher and the student as mutually active participants, a move toward functional social communication in natural contexts, has demonstrated many improvements in speech and language skills, as well as a lowering of disruptive and self-stimulatory behaviors. The down side of milieu teaching is the high degree of clinician control (withholding a desired item until the child requests it), and the need for adult prompting. Teachers, parents, and caregivers must be specifically taught to provide or increase opportunities for social interaction to bring significant gains. By relying on the child's self-initiation, rather than focusing on adults as the primary source of learning, the child's autonomy would increase with the potential for learning outside of a specific teaching context. Since questioning is the first real communicative social interaction that leads to further speech, children are taught "what's that?, to increase their expressive vocabularies of noun labels, and to further motivate their accomplishments. The prompts are gradually diminished with students using query as a tool to access further linguistic information through reciprocal interaction. "Where is it" is added in to teach specificities and localization, and "whose is it?" to learn possession. "What happened?" furthers the use of verbs in the past tense Because communication difficulties are universally present in individuals with autism, including problems in social communication and joint attention, these deficits in social communication or social interaction may be the primary underlying cause of autism. There appears to be a direct correlation between communication and language difficulties and other inappropriate behaviors, such as aggression, self-stimulation, and self-injury. "This emphasizes the importance of communication intervention as a primary goal in the habilitation process and suggests that many untreated aberrant behaviors are likely to show concomitant positive changes as communication improves". (Koegel, 1995,pp17) Language characteristics of children with autism fall into three categories:
Seventy percent of the fifty percent of children with autism who are completely nonverbal can learn at least some expressive language if commenced before 5 years of age. Naturalists work with the notion of developmental continuity from preverbal to verbal levels. These communicative intentions can be taught through the use of gestures, simple signs, or pictures, in place of physical manipulation to request objects. Appropriate behaviors that meet the same communicative needs can also be taught to replace undesired behavior. Students that have some speech, even with marked delays, can benefit from interventions and may be capable of moving into quantitative and qualitative communication. Children with autism tend to use communication most frequently for requesting objects, requesting actions, and protesting. They also display fewer social responses, which leads them to few communicative interactions and communicative incompetence. If seen as a self-stimulatory function, the echolalic utterances appear to serve no language purpose. Teaching children with echolalia to reply 'I don't know' or 'I don't understand' has proven to be an affective generalized strategy to reduce the immediate echolalia and provide the child with a socially appropriate response. Some echolalic utterances appear to be a method of avoiding interactions and may be misconceived as appropriate language. By interspersing questions with a second related question (e.g.-if when you say 'do you want to go bye-bye' the child says 'bye-bye', you then ask 'what do you want to do' and see if the child says 'do' or 'bye-bye') you can assess if the child is engaged in appropriate social interaction. Children with autism usually interact with only a very restricted number of stimuli, and rarely interact in social and other environmental situations. It is hypothesized that motivational problems begin early in life when children repeatedly experience failure due to central nervous system dysfunction, causing depressed motivation and task and social avoidance. Focusing on targeting 'pivotal behaviors', behaviors likely to affect wide areas of functioning, motivates the children to interact academically, linguistically, and socially. It is believed that a motivational program begun very early in life helps students learn that responding and reinforcing are independent if they are connected to constant failure. When students experience years of repeated exposure to failure "they appear to learn that responding and reinforcement are independent". "Such conditions result in a decrease in the individual's level of responding or a failure to respond altogether". (Koegel, 1995,pp.7) "One of the most significant implications of a children's lack of motivation relates to other individuals' perceptions of the child's competence. That is, persistent lack of motivation to make even feeble attempts at learning new tasks can manifest itself in either extreme lethargy or in active avoidance of teaching or assessment tasks. It is common for such children to exhibit aggression, self-injury, property destruction, and other severe disruptive behaviors in an attempt to escape or avoid such tasks". (Koegel, 1995,pp.7) The self-fulfilling prophecy then comes into play when the Individualized Education Plan (IEP) underestimates the child's functioning level, testing instead the child's motivation to respond. Placed in a more restrictive environment with faulty educational goals exacerbates the problem, creating a combination of segregation and lack of academic challenges which devastates the child's long-term development. Attempts to communicate need to be reinforced to provide for verbal response. This is in contrast to the traditional techniques where strictly defined, correct, and successive approximations to a target are reinforced. The material stimulus should be 'child choice' with task variation. Maintenance trials (tasks already mastered) need to be interspersed with new acquisition trials. Natural reinforcers, directly related to the child's response, improve motivation and aid in increasing response acquisition. Where similar types of reinforcers are available, increasing the breadth of the child's responding, there will be an increase in the likelihood of generalization to other environments. Where functional communication is taught (e.g.-"help me") there has been shown to be a reduction and eventual elimination of 'acting out' behaviors. "A large body of research now exists suggesting that certain children with autism respond to overly restrictive portions of …complex stimuli". (Koegel, 1995, pp.11) These children tend to respond only to a small portion of the total complexity. They may respond to only one clue (e.g.- recognizing an adult by their glasses, and not recognizing them when their glasses are not there) a response which appears to be highly stable over time and not likely to change without intervention. This overselectivity can be modified with a technique called 'within-stimulus prompting', where children respond to a relevant cue by exaggerating the relevant component of the complex stimulus in question. While not altering the fundamental problem, selectivity is effective in improving learning. With an attempt to broaden developmental implications, Koegel suggests gradually and systematically increasing the number of cues the children use. Conditional discrimination provides reinforcement only when they respond to a learning task on the basis of multiple cues. Eventually students generalize the strategy to novel learning tasks. Some people, like Wetherby (2) advocate gestural, rather than vocal communication training. She believes in building on the child's existing strengths (giving, pointing, pushing away, head shaking, nodding) as the foundation for teaching words, through speech or signs. Schuler and Baldwin (5) point out that nonspeech methods allow easier access to communication where there has been a breakdown in speech. Nonspeech responses include prompting or 'molding' by guiding the student's hands through the required responses but reminds us that this can not teach speech. AAC Technology Solutions, another approach, refers to Augmentative and Alternative communication, which is the application of assistive technology through visual language systems to create and/or enhance existing communication modalities in individuals with disabilities. Natural Aided Language (NAL) is an augmentative communication strategy in which visual symbols (icons or words) are placed on an environmentally specific language board or technology device for the purpose of facilitating interaction and participation in an activity. Communication partners touch key words on the language board while saying those words so that receptive language training is occurring naturally during the activity. Visual language is viewed as a legitimate and real language and every activity, environment and potential communicative need is interfaced with a visual language board with or without an AAC device. Everyone in the child's environment takes responsibility for using and implementing language. Intensive receptive language stimulation, without pressure, is enforced by family, peers, and professional helpers. NAL utilizes the best practices of naturalistic learning, natural language strategies and AAC, providing opportunities for children with autism to learn skills in real and meaningful environments, with reinforcers contextually related to the activity itself. Spontaneous comments, questions, or the offer of information shows up as a marked deficiency in children with autism. Another piece of technology is a tactile prompting device called The Gentle Reminder which is used to initiate and encourage verbalization, and it beeps or vibrates for several seconds at specific intervals (eg-once every 60 seconds). While research showed that more verbal interaction occurred with the use of this device, spontaneous initiation did not. Technology can also be seen in voice output communication aids (VOCAs) which augment and alternate communication. These aids involve activation of a device, which provides recorded or synthesized speech. Messages of varying length and content, easily understood by individuals, provide the potential to gain attention. Symbols or simple printed words are used to identify messages. Schepis et al. (1998) point out that not enough research has been done in this area. Another method of reaching autistic children is social stories, used for students with deficits in social cognition. These stories aid the ability to think in ways necessary for appropriate social interaction. Assuming the perspective of another person can be addressed through a technique where students 'read' and understand social situations. In the form of a story these presentations of appropriate social behaviors are meant to answer questions that individuals may need to know. Descriptive, directive, perspective, and control sentences give individuals the opportunity to learn and provide their own responses to social situations. Verbal people with autism usually display semantic pragmatic impairments. This language disorder can be looked at within a medical framework. Rapin and Allen (6) describe various syndromes, which would include verbal auditory agnosia, semantic-pragmatic disorder deficit, verbal dyspraxia, phonological-syntactic disorder, and lexical-syntactic deficit. Bishop and Rosenbloom (7) considered a continuum of specific problems with language use and content as a set of loosely associated behaviors which shaded into autism at one extreme and normality at the other, which includes meaningful verbal communication and interests and social relationships. Aarons and Gittens (8) saw the social impairments as the most important diagnostic indicator. Brook and Bowler (9) stated that "semantic-pragmatic disorder" and "high-level autism" were different perceptions of the same phenomenon. Boucher (10) saw the diagnostic criteria for 'semantic-pragmatic disorder" as a valid sub-type of autism. (Shields 11) warned about the dangers of using a diagnostic label to mask the underlying socio-cognitive deficits and restrict the available help for the child's special educational needs. With all the new research and findings going on, we need to begin to rethink our old perceptions of autism. If we can begin to look at mutism and unusual speech as neurologically based, a problem of praxis rather than cognition, we can then open ourselves to alternative interpretations. While not the first, The Dignity Through Education and Language Centre (DEAL) in Melbourne, Australia helps non-verbal or echolalic students, usually labeled retarded, with facilitated communication. Crossley first discovered literacy skills among non speaking people or people with disordered speech (autism, developmental disabilities) during the 1970's when she was working at St. Nicholas Hospital, a residential institution, while offering arm or hand support to people with cerebral palsy. She believes in the student's capacity to learn and express themselves. She engages them, speaking personally and directly to them, never patronizing, always finding ways to reveal their competence. In facilitated communication the teacher, or assistant, rests their hand under the student's forearm, providing support for the arm as the student selects keys on a computer keyboard or facilitated communication board. These students have been challenging the traditional assumptions about autism. It gives students who can not speak another mode of communication. Through the use of facilitated communication student's echoed speech , which may have been learned by rote, is shown not to be reflective of his intellectual abilities, specifically his ability to engage in abstract ideas. It may be that these students who couldn't communicate, became observers who focused their intellectual energies on understanding language and on learning to read. His disability caused him to focus on intellectual activities such as ordering numbers, noting spatial designs, and reading. In the past echoes were used to accomplish functional communication, with the resultant language appearing to be based on a limited linguistic system. The echolalic patterns were joined to form new utterances, connect related but containing ungrammatical form and atypical syntax. Prizant and Duchan (12) categorized the echoes of four children with autism into categories: turn-taking, declarative expressions, yes answers, requests, nonfocused expressions, rehearsals, and self-regulatory expressions, in an attempt to decipher the communicative intent. They were one of the first studies to attribute social meaning to echoed language. While adding on one year later: providing information, verbal completion, protest, calling, self-directives, and directives, Prizant and Rydell (13) felt that individuals with autism initiate interaction motivated largely by the need to ensure predictably by maintaining an established routine. Such language gives the impression on an inability to use creative and generative linguistic processes, leaving one with the assumption that the limitations are derived from lack of cognition. Due to insufficient cortical control of the limbic system, it is presumed that vocal signals of low informational value, lacking emotional reactions or self-stimulatory responses, would be the maximum achieved. While gestural communication may hold promise for modeling spoken language, we must also hold dearly the possibility that autism may not hold social and cognitive deficits "Apraxia does not necessarily imply cognitive deficit" (Biklen 1993, pp. 65). While we may contemplate the hypothesis of Crossley (14) and Oppenheim (15) that people with autism experience global apraxia affecting literally all aspects of voluntary physical activity, we must also keep open to the fact that the thinking abilities of people with apraxia far exceed their capacity for expressive language. Automatic, echo-like expressions can be observed in any one's speech. Because of prior associations, people give automatic responses, which would not be the same response that would likely be given if thought had been given. Slowing down the person with autism gives them a better chance at intentionality, rather than automatic words. Biklen (1993) reminds us of the importance of independence and interdependence. Through facilitated communication a student reminded him that dependency gave her a close relationship and time with her speech therapist and some support and help with behaving in a reasonably acceptable way. To this student interdependence meant doing things on her own, which meant settling for lower levels of accomplishment than she was willing to accept. For this student a "light touch on her elbow told her that she was totally safe and that success was a constant and real possibility". Facilitated communication is still rather controversial, with some still believing that the facilitator is taking charge of the student. While achieving good results it is hard to prove what some see as the impossible, individuals with outer autistic behavior showing the capacity to speak coherently and with empathic meaning. Koegel (1995) reminds us that even though independent responding is directly related to motivation, repeated failure to respond to the environment results in overdependency on others. This can exacerbate a cyclical reaction in which the child learns that that his or her own responding is unrelated to the consequences of his or her behavior. This problem can be pervasive and persist into adulthood, such that even simple self-help skills require an inordinate amount of help from others. Koegel reminds us of the importance of using not only motivational interventions, which can be extremely effective, but also the importance of producing "widespread use of newly learned behaviors in a large variety of natural environments where generalization may not readily occur. Self-management as a pivotal behavior is ideal for this purpose, because it can be used for extended periods of time in the absence of an intervention provider and it is easily adapted for use in a wide variety of natural environments" (Koegel 1998,pp.12).Self-management greatly increases children's roles as active participants in their own growth process, reducing dependency on parents and other adults. Axt (1998) advocates the use of Sandplay for high functioning autistic adolescents. This therapy, first used in England by Dr. Margaret Lowenfeld, a Freudian psychiatrist, later developed by Dora Kalff, a Jungian analyst in Switzerland, and currently worked with by Estelle Weinrib in the USA, is a non-verbal, non-rational form of therapy that reaches the preverbal level of the psyche. Based on the hypothesis of a fundamental drive in the human psyche towards wholeness and healing, the basic sandplay equipment allows for no interpretations, or judgements, or directions, or comments given. It means that socially awkward children, involved in repetitive behavior, insisting on sameness, sensitive to noise and smell, can start to heal in a free space with unconditional acceptance. Other interventions to look at are auditory-based techniques, such as auditory integration training and audio-psycho-phonology methods, based on the belief that autism occurs because of auditory dysfunction including attention, hyper-and hyposensitivity, and central auditory processing. AIT devices process music in two ways: 1) modulation uses low and high frequencies selected from a music source (audiotape or CD) and presents random intervals to the listener, 2) narrow band filters are used to filter out specific frequencies that the listener hears too acutely. Alfred Tomatis developed a neurophysiological and psychosocial theory as a framework for auditory stimulation. He believed that the auditory system must be intact and operational at the neurophysiological level and at the psychological level (motivation and desire must be present). Tomatis defines listening as a functional and motivational process of focusing the ear. His theory states that the quality of mother-child interaction in the pre-and postnatal periods affects listening and psychological factors that can decrease the child's motivation to listen. This methodology works at the functional level. The client sings or speaks into a microphone that feeds back into the Electronic Ear. This speech is modified by amplifying the high frequency components. Work is done on the emotional level (the mother's voice is used as the stimulus, filtered in a manner that stimulates how it would be heard as a fetus, then as a newborn, then as an infant, in the belief that a difficult prenatal life, traumatic birth, or early separation from the mother impaired the child's listening ability), and on the relational level (the parents receive counseling to help them to understand a child who has behavioral or learning-related problems that often create confusion in their environment). The auditory stimuli, presented simultaneously through earphones and a bone vibrator, is generally received 150-200 hours over a 6-12 month period. The Tomatis method is useful for children with delayed or disordered language and with behavioral and emotional problems. Another approach, the Berard method, believes that certain people have hypersensitive hearing at select frequencies, which cause agitation, pain, and interference with learning. Audiogram readings that have peaks and valleys that differ by 5 db or more, reflect auditory abnormalities that may result in learning, behavioral, or emotional problems. Treatment is conducted with a device Berard designed called the Ears Education and Retraining System (EERS) or Audiokinetron. Sound input is used which contains very broad frequency stimulation with randomly varied intensity of low and high frequency stimuli so the listener does not anticipate the stimulus presentation, and filters set to attenuate the frequencies where peaks are present. Audiograms are repeated at midpoint in the treatment to determine if filter settings need to be changed. The Berard method is recommended for people with learning disabilities, behavior disorders, autism, pervasive developmental disorder, attention deficit hyperactivity disorder, tinnitus, hyperacusis, as well as depression. The Society for Auditory Intervention Techniques provides the following basic information and recommendations for auditory intervention:
A consequence of auditory interventions, and of the lessened difficulty with hearing, may be some gain in social awareness or verbalization. It should not be expected to cause all of a person's autistic characteristics to disappear. Some people report that the effects of AIT seem to fade after some time, with some individuals reporting no benefits at all. Another technique that may address auditory processing problems is the FastForWord software package, targeted for children 4-12 years of age, with language learning impairments in the auditory processing area. This program slows down and clarifies speech sounds, focusing on speech and sound comprehension. Samonas or Spectral Activated Music of Optimal Natural Structure, based on the Tomatis method, incorporates recent advances, and believes that overtones are rich in energy and have a different effect on the mind and body than low tines, which may have a draining effect. The music used has been specially recorded to emphasize the overtones that may be lost in the music we listen to regularly. Listening programs are individualized, and headphones are used. Sensory Integration provides another therapeutic approach. It works with over or under reactive senses to stimulation. These problems are believed to stem from neurological dysfunction in the central nervous system. Such techniques as pressure-touch can facilitate attention and awareness, and reduce overall arousal. The focus is on tactile, vestibular, and proprioceptive senses. The interconnection between these basic senses is complex, allowing us to experience, interpret, and respond to different stimuli in our environment. These responses are critical to human survival. The dysfunction may express itself in withdrawal from touch, textures (e.g.-food and clothing), a preference to use one's finger tips rather than whole hands, avoiding getting dirty or having one's hair or face washed. Tactile defensiveness describes a tactile system that is immature, sending abnormal neural signals to the cortex in the brain, which can interfere with other brain processes. This over stimulation leads to excessive brain activity, which makes it difficult to organize behavior and to concentrate. Individuals with autism are hypothesized to have an immature tactile system. Additionally, a vestibular system dysfunction may be seen as hypersensitivity through fear of ordinary movement activities. Climbing and descending stairs or hills, as well as apprehensive walking or crawling on uneven or unstable surfaces, is expressed in fear in space. Individuals with sensory integration problems appear clumsy, or actively seek very intense sensory experience (body whirling, jumping, spinning). They are trying to continuously to stimulate their vestibular system. With dysfunction one would see clumsiness, a tendency to fall, a lack of awareness of body position in space, odd body posturing, minimal crawling when young, difficulty manipulating small objects (eg.-buttons, snaps), eating in a sloppy manner, and resistance to new motor movements. Praxis, the ability to plan and execute different motor tasks (such as speech) relies on accurate information from the sensory system, as well as organizing and interpreting this information efficiently and effectively. Occupational and/or physical therapists can evaluate and develop the treatment. The goals would be to provide sensory information to organize the central nervous system, assistance for the child in inhibiting and/or modulating sensory information, and assistance in processing a more organized response to sensory stimuli. Movement activities which encourage climbing, walking and swinging, body rubs, protection from noise, body pressure, and sitting on a beach ball or T-stool are preventive methods to short-circuit behavior problems, (i.e.-respite from stress, and stress relieving mechanisms are encouraged). Concerned parents, determined to find help for their children, are beginning to explore diet and immune modulating therapies. Hyman and Levy (2000) refer to complementary and alternative medicine (CAM) therapies. They suggest that only one change in treatment be made at any one time, including educational and therapeutic treatments. They evaluate treatment by selecting a response that can be measured, identify target behaviors for treatment, establish a baseline for skill or function, monitor response to therapy prospectively, consider each child as his or her own control, use valid and objective outcome measures when possible, and they use raters who could be blind to treatment, such as a teacher. They remind us to be knowledgeable about potential side effects of any treatment and the importance of keeping lines of communication open between families and physician, even if both parties do not agree with the course of treatment. They highly suggest not to abandon standard educational and therapeutic treatments, and, above all, to do no harm. CAM treatments that are currently popular can be categorized into several groups: vitamins and supplements, dietary manipulations, alternative uses of biologic agents, immune therapy, and nonpharmacologic therapies. Advocates of vitamin and supplement therapy suggest that vitamins enhance neurotransmitter actions by increasing availability of substrate or cofactors. Vitamin C (ascorbic acid) inhibits central dopamine action, which may be abnormally increased in ASD. Vitamin B6 (pyridoxine) is said to generate several neurotransmitters (serotonin, dopamine, gamma amino butyric acid, norepinephrine, and epinephrine) and, when combined with magnesium increases clinical response. Dimethylglycine (DMG) is a nutritional supplement that may have excitatory central neuroactive effects similar to those of the excitatory neurotransmitter, glycine. Vitamin A has been hypothesized to improve immune function. The role of restrictive diets is also being evaluated. Sugar, preservatives, aspartame, milk, and wheat are removed with the hypothesis that children with autism have a "leaky gut". "This is thought to lead to increased absorption of peptides with the bioactive properties of endogenous opioids" (Hyman and Levy,2000). They suggest that variants of celiac disease, a side effect of yeast overgrowth, a primary immunologic abnormality, or enterocolitis as a sequela of immunization, may be at the center of the problem. Antiyeast therapy, based on the suppostion that children have an intestinal overgrowth of yeast because of an immunodeficiency or a history of excessive antibiotic use, requires the use of dietary supplements and medications. Secretin, a pancreatic hormone that mediates digestion, was recently proposed as a possible cure for autism. Famotidine (Pepcid), a histamine-2 receptor antagonist in wide clinical use for symptoms of gastroesophageal reflux and heartburn, has been investigated as a potential treatment for schizophrenia and autism because H2 receptors in the brain are related to exploratory behavior and activity in animals. Alkaline salts and antacids are being used to alter stomach pH to stimulate natur4al secretion of secretin and other gastrointestinal peptides. Immunologic therapies have been introduced as a clue to infectious or autoimmune etiology. Reported abnormalities have included low immunoglobulin A or immunoglobulin G, abnormal levels of T and B lymphocytes, decreased numbers of natural killer cells, and antibodies to myelin basic protein. Langford (unpublished) suggests that foremost is the home testing for thyroid function and its support. He states that elimination of bowel disorders is first on the list, with digestive enzyme supplements or removal of milk from the diet helping dramatically. Dependending on the damage to the duodenum and small intestine, and the stomach's ability to produce adequate hydrochloric acid (HCl) for proper digestion, an infusion of the intestinal hormone secretin may be beneficial. Along with adequate zinc, and possibly supplemental betaine hydrochloride, secretin infusion may be totally unnecessary. Langford tell us that, even though the path of autism is different for each child, in all children with autism and ADHD have a deep disturbance in their fatty acid metabolism that impairs their utilization of amino acids, and often there is an imbalance in their electrolytes, which control what goes in and out of the cells and provides nutritional balance. Until the electrolyte (sodium-potassium-magnesium-calcium) imbalance is corrected, nutritional supplements are relatively ineffective. The following nutritional abnormalities exist in all or most autistic children: zinc, calcium, magnesium, omega 3 fatty acid, fiber, antioxidant deficiencies, and copper excesses. Langford also reminds us to watch out for heavy metal poisoning with elevated Copper/Zinc (Cu/An) ratios in the blood, suggesting a disorder of metallothionein (MT), a short, linear protein responsible for homeostasis of copper and zinc and many other metals. William J. Walsh, Ph.D., Physician, biochemist and chief scientist of the Pfeiffer Treatment Center, Naperville, Illinois suggests that copper overload and zinc depletion are the most common metal-metabolism in behavior conditions such as ADHD, autism, depression, bipolar disorders, and schizophrenia. Individuals with these disabilities are unusually sensitive to lead, cadmium, mercury, and other toxic metals which they tend to accumulate rather than eliminate. Blood and urine analysis yielded evidence of a metallothionein dysfunction in 499 of 503 patients (99%) diagnosed with autism spectrum disorders, according to Walsh, suggesting that autism may be caused by either a genetic MT defect or a biochemical abnormality, which disables MT protein, affecting the development of brain neurons and may cause impairments in the immune system and gastrointestinal tract, along with hypersensitivity to toxic metals. He suggests that the excess copper is probably from two causes: mercury depresses zinc, and there is a high incidence of zinc malabsorption. To reduce copper it is suggested to use significant amounts of vitamin C and zinc. Langford suggests that we ensure adequate production of hydrochloric acid, or supplement Betaine hydrochloride . Supplement with digestive enzymes (SpectraZyme, EnZym-Complete, Peptizyde, SerenAid or EnzymAid- all trade marked products), as well as indicated amino acids, fatty acids, probiotics, vitamins, minerals, glyconutrients, and phytonutrients, should be attempted to restore thyroid function which controls enzyme production of the pancreas. It is imperative to give nutritional intervention to restore iodine, selenium, zinc, and tyrosine to high-normal levels, as well as to restore thyroid function. Homeopathic vaccine detox that removes mercury and aluminum as well as other poisons pumped into children through vaccines, is also suggested. Medically, it is suggested to test for heavy metal poisoning and to chelate as indicated. Shattock (1990) suggests that we look at diet, specifically of peptides derived from food proteins. These peptides, found in the urine of autistic patients, were found to be leftovers from incompletely digested proteins. When the body functions well, it absorbs these peptides into the bloodstream, penetrating the blood brain barrier (BBB). These peptides are called exorphins. When autistic individuals eat foods containing gluten or mild products in large amounts, casomorphins or glutomorphins, harmful exorphins, may reach the brain rather than breaking down and being absorbed. This combination of harmful exorphins and the needed endorphins, needed for proper functioning of the nervous system (endorphins and opioids) create a chaotic reaction in the brain of an autistic person, hindering the functioning of the body's own opioids. This imbalance can influence the energy production that occurs in the brain, affecting the immune system and creating symptoms, such as 'leaky gut'. Axt (1998), while acknowledging that autism is a difficult condition to understand, and having had the experience of working with more than one hundred autistic children over a twenty five year period, has done studies which led to the hypothesis that problems of autism stem from an impairment of pineal gland functioning. She suggests a therapeutic strategy, a success for her, involving the application of bodywork techniques such as Craniosacral Therapy, Polarity Therapy and the Metamorphic Technique in conjunction with the administration of supplemental, exogenous melatonin. These treatments aim at restoring the functioning of the pineal gland and the bioenergetic and biochemical balance in the body. Summary Autism is classified as a pervasive developmental disorder in which there is an abnormal functioning in the areas of social interaction, communication, and patterns of behavior, interest, and activities manifesting before three years of age. People with Autism generally have an impairment in the use of nonverbal behaviors, failure to develop appropriate social reactions, stereotyped and repetitive use of language, or lack of communicable language, lack of social, imitative play, persistent preoccupation with ritual and lack of, or locked in focus. This interprets into an inability to relate to others, a failure to develop speech, abnormal responses, and insistence on sameness. These individuals are usually found to be hyper or hypo-sensitive in their senses with a tendency for aggression, self stimulation, and self-injury. They have been found to have good cognitive potential with excellent rote memory. Language abnormalities are seen to be the central symptom of autism. Mutism, echolalia and perseverative speech, with delays in language development and atypical expressions, rote speech, and little understanding of abstract concepts, being common. There are incorrect semantics, lack of flexibility, undeveloped pragmatics, lack of affect, and displays of tantrums, aggression, avoidance, or attention-seeking behaviors. Social impairment can be seen as the core symptom. Early language work with children with autism involved operant training technology, focusing on teaching verbal imitation. Distractions were removed, a stimulus presented, and the child prompted with rewards and punishment. Aversive stimulation was used for aggression, self-injurious, or disruptive behaviors. Phonemic behaviors were taught, outside of its social context. Sessions were highly controlled. Children exhibited a lack of spontaneity and the language failed to generalize to other environments. Naturalistic teaching evolved as an attempt to solve problems of generalization and maintenance, resulting in increased motivation and responsivity. Opportunities involving the use of naturally occurring opportunities focused on behaviors of immediate functional utility. There was a shift from teacher prompt to child interest, from consistency to functionality more closely resembling the way typically developing children learn naturally to speak. Naturalistic interventions focused on functional language skills in a social context, an environment with increased opportunities to use language. Tasks to be mastered are child choice, interspersed with learned material, multiple exemplars in natural environments, rewarded for attempts, place emphasis on turn taking and interaction, and have shown a demonstrated improvement in speech and language skills and lowering of disruptive and self-stimulatory behaviors being the outcome. Gestural communication builds on existing strengths allowing easier access to communication where there has been a breakdown in speech. Augmentative and Alternative Communication (AAC) uses assistive technology through visual language systems to create or enhance existing communication modalities. Natural Aided Language (NAL) provides visual symbols (icons or words) placed on a language board or a technology device to facilitate interaction and participation. A tactile prompting device (the Gentle Reminder) initiates and encourages verbalization at timed intervals and voice output communication aids (VOCAs) augment and alternate communication. With this synthesized speech, messages of varying length and content can be easily understood by others. Social stories present appropriate social behaviors giving individuals the opportunity to learn and provide their own responses to social situations. The Dignity Through Education and language Centre in Melbourne suggests that we look at mutism and unusual speech as neurologically based, a problem of praxis rather than cognition. Working on a computer keyboard or facilitated communication board , with minimal arm support being provided, has provided us with communicative students challenging traditional assumptions about autism. These students who can not speak are responding with an intellect that shows an ability to engage in abstract ideas. Sandplay allows socially awkward children, involved in repetitive behavior, insisting on sameness, sensitive to noise and smell, to start to heal in a free space with unconditional acceptance. Auditory integration training and audio-psychophonology methods are based on the belief that autism occurs because of auditory dysfunction, including attention, hyper- and hypo-sensitivity, and central auditory processing. AIT devices process music through modulation of low and high frequencies presented in random intervals, and narrow band filters used to filter out specific frequencies. Sensory Integration works at the level of sensation believing that the problems stem from neurological dysfunction in the central nervous system. Complementary and alternative medicine (CAM) suggests the use of vitamins and supplements, dietary manipulations, alternative uses of biologic agents, immune therapy, and non-pharmacologic therapies. Therapeutic strategies involving the application of bodywork techniques such as Craniosacral Therapy, Polarity Therapy and the Metamorphic Technique in conjunction with the administration of supplemental, exogenous melatonin aim at restoring the functioning of the pineal gland and the bioenergetic and biochemical balance in the body. We want our students to achieve, to work independently, and interdependently, to feel motivated, to be effective in what they do, and to find their place within society. Prevention and treatment begins before birth. A quick diagnosis encourages prompt follow up and support. As teachers if we can remember to teach each student, beginning at their ability, and guided by their self-motivation, we will be able to bring the next generation from their dysfunction and inabilities, to their strength and realization of the role they can play, with self, and other. While there are many therapies available, and many more becoming cognizant daily, it is not until we accept and understand each student from their point of beginning, to their core of being, that we will be truly present and available, as the teachers we are meant to be. Referencess Rutter, M. & Schopler, E. Diagnosis and Definition, Autism: A reappraisal of concepts and treatment, Plenum Press. N.Y., 1978 Wetherby, Possible neurolinguistic breakdown in autistic children. Topics in Language disorders, 4, 19-33. 1984 Churchill, The relation of infantile autism and early childhood schizophrenia to developmental language disorders of childhood. Journal of autism and childhood Schizophrenia 2, 182-197, 1972 Wing, The continuum of autistic characteristics. In E. Schopler & G. B. Mesibov (Eds.) Diagnosis and Assessment in Autism., N.Y. Plenum, 1988 Schuler and Baldwin, Nonspeech communication and childhood autism. Language, Speech, and Hearing Services in Schools, 12, 246-257, 1981 Rapin, I. & Allen, D., Developmental language disorders: nosologic consideration. In U. Kirk (Ed.) Neuropsychology of Language, Reading and Spelling .New York: Academic Press, 1983. Bishop, D.V.M. & Roenbloom, L. Classification of childhood language disorders. In W. Yule & M. Rutter (Eds.) Language Development and Disorders. Clinics in Developmental Medicine, No. 101/102. London: MacKeith Press, 1987. Aarons, M. & Gittens,T. What is the true essence of autism? Speech Therapy in Practice, January, 1990. Aarons, M. & Gittens, T. Autism as a context. College of Speech and Language Therapists Bulletin, pp. 6-8, December 1991. Aarons, M. & Gittens, T. Semantic-pragmatic disorder (or a little bit autistic?) College of Speech and Language Therapists Bulletin, pp. 18, June1993. Brook, S.L. & Bowler, D. Autism by another name? Semantic and pragmatic impairments in children Journal of Autism and Developmental Disorders, 22, pp. 61-81, 1992. Boucher,J. SPD as a distinct diagnostic entity: logical considerations and directions for future research. International Journal of Language and Communication Disorders. 33 (1), pp. 71-108., 1998. Shields, J., et al. Hemispheric function in developmental language disorders and high level autism Developmental Medicine and Child Neurology, 38, pp. 473-486, 1996. Prizant and Duchan, The functions of immediate echolalia in autistic children. Journal of Speech and Hearing Disorders, 46, 241-249 Prizant and Rydell, Analysis of functions of delayed echolalia in autistic children. Journal of speech and hearing research, 27, 183-192 Crossley, Unexpected communication attainments by persons diagnosed as autistic and intellectually impaired. Paper presented at International Society for Augmentative and Alternative Communication, Los Angeles, October 1980 Oppenheim, Effective teaching methods for autistic Children. Springfield, IL, 1974 Bibliography Books: Biklen, Douglas. Communication Unbound: How Facilitated Communication Is Challenging Traditional Views of Autism and Ability/Disability. Special Education Series. Teachers College, Columbia university NY, 1993. Koegel, Robert L., Koegel, Lynn Kern. Teaching children With Autism: Strategies for Initiating Positive Interactions and Improving Learning Opportunities. Paul H. Brookes Publishing Co, Baltimore, 1995. Maurice, Catherine. Let me Hear Your Voice: A Family's Triumph Over Autism. Alfred A. Knopf, NY, 1993. McKean, Thomas A. Light On The Horizon: A Deeper View From Inside The Autism Puzzle. Future Horizons. Texas. 1996. McKean, Thomas A. Soon Will Come The Light: A View from Inside the Autism Puzzle. Future Horizons. Texas, 1994. Diagnostic and Statistical Manual of Mental Disorders-DSM IV. American Psychiatric Association. Webster's' New Twentieth Century Dictionary, unabridged. Simon and Schuster, NY, 1979. Internet Articles:
Bishop, D.V.M., Autism, Asperger's syndrome and semantic-pragmatic disorder: Where are the boundaries? Department of Psychology, University of Manchester.
Cafiero, Joanne M. Increasing Communication Skills in Students with Autism Spectrum disorders: The AAC Technology Solutions.
Fussell, Susan R. Ph.D., Communication of Affect and Emotion. Human-Computer Interaction Institute Carnegie Mellon University.
Hatch-Rasmussen, Cindy, M.A., OTR/L, Sensory Integration.
Shields, Jane Dr., Semantic Pragmatic Impairments: Information Sheet
Auditory Integration Training and the Audio-Psycho-Phonology Method
Internet:
Autism support/education group
Journals: Assagioli, Roberto. Creative Expression in Education: Its Purpose, Process, Techniques and Results, Journal of Education, Vol.145, No. 3, February 1963 by Psychosynthesis Research Foundation, "Valmy, "Greenville, Delaware Axt, Andrea, PhD, RPP, FQM. Autism Viewd as a Consequence of Pineal Gland Malfunction. Farmakoterapia W Psychiatrii I Neurolgii, 98,1,112-134 (available on the web at http://www.attcanada.net/~hanavi) Axt, Andrea, PhD, RPP, FQM. The Use of Sandplay in Therapy with a High Functioning Autistic Adolescent. Play Therapy. Professionals Section. 1988. Hyman, Susan L. MD, Levy, Susan E. MD. Autistic spectrum disorders: When traditional medicine is not enough. Contemporary Pediatrics, vol. 17, No. 10, October 2000. Schepis, Maureen M., Reid, Dennis H., Behrmann, Michael M., Sutton, Kelly A., Increasing Communicative Interactions of Young Children with Autism Using A Voice Output Communication Aid and Naturalistic Teaching. Journal of Applied Behavior Analysis, volume 31, Winter, 1998, Number 4. pages 561-578 Shattock P., Kenedy A., Rowell F., Berney T., role of neuropeptides in autism and their relationship with classical neurotransmitters, Brain Dysfunction, 19903:328-345 Taylor, Bridget A., Levin, Len. (Alpine Learning Group), Teaching a Student with Autism to make Verbal Initiations: Effects of a Tactile Prompt, Journal of Applied Behavior Analysis, volume 31, Winter 1998, Number 4., pages 651-654. Papers: Langford, Willis S., A comprehensive Guide to managing Autism. Unpublished. Videos:
Breakthroughs: How to Reach Students with Autism, Attainment Company Production, 1998
The Autism Continuum by Dr. Temple Grandin
Public Schools with Students with Autism: Components of a Defensible Program, 1999 |