Inhibidores de la COX-

Autism manifests itself in significant behaviour and communication differences including abnormal social and communication skills and restricted interests and activities (White et al, 2012). Children with this condition display a preference for solitude and are often described as ‘aloof’, ‘remote’ and ‘living in a world of their own’ (Christie et al, 2009). Other characteristics include a dislike of changes in routine, the use of objects in unconventional ways (eg spinning wheels of toy cars repeatedly), stereotyped and repetitive motor movements, severe tantrums and self-injury and delays in age-appropriate self-help skills such as dressing and grooming (Ben-Arieh & Miller, 2009). Symptoms begin in early childhood but may not be fully recognised until social demands exceed the child’s capacity to cope (Hyman, 2013). Since there is no chromosomal marker or physiological feature evident it is only by observing the child’s behaviour that one can say that a child has an ASD and only by analysing that behaviour that one can understand the child’s needs and find strategies that suit those needs (Hanbury, 2012).

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Figure 2.1 Reciprocal interaction of biological, environmental and behavioural factors

(Source: Whitman and DeWitt, 2011)

Communication difficulties range from not understanding or using spoken language at all to having an above-average vocabulary but without having much to say that could be described as mutually conversational. Communicative autistic learning disabilities (ALDs) include problems understanding body language and facial expression, using expressive body language and facial expression, and comprehending and using spoken language. Impairments in reciprocal social interaction map onto three main areas of social ALDs: a lack of awareness of others as they live in their ‘own little worlds’; a lack of social and emotional reciprocity which leaves them uninterested in having social interaction that please (or displease) parents or teachers and which leads to them losing out on early learning stages; and finally a lack of social imitation which closes a main source of new experiences for them (Siegel, 2003).

2.2.2 Models of Autism

A number of models have been proposed to explain the characteristics of autism since Kanner’s seminal work (1943) in which he described a group of children who did not relate to others, had delays in speech development, engaged in repetitive behaviour and were upset with changes in routine (Kirk et al, 2012). Each of these models helps to

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provide an insight into a particular aspect of autism and can be used to understand the experiences of the individual with autism from their perspective. These models can assist caregivers in identifying children’s strengths and weaknesses so that they can begin to support their progress in the ways that suit them best (Hanbury, 2012).

The concepts described below form part of the conceptual framework which underpins current thinking in the field of autism. It is important to consider this framework as ever-changing as knowledge of the condition increases (Hanbury, 2012).

2.2.2.1 Triad of Impairments

The Camberwell study conducted by Wing and Gould (1979) found all the children with ‘autistic features’ showed an absence or impairment of social interaction, communication and development of imagination. The strength of Wing’s model (2002) is that it is flexible enough to cover the full range of the autistic spectrum and thus allows one to view each child’s condition uniquely. Although it is necessary for all three core deficits to be present (ie impairments in social communication, social understanding and imagination) (Figure 2.2), the degree to which each of these components affects the individual with autism varies from person to person. For some individuals one element of the triad may be particularly marked, while other individuals may manifest significant difficulties across two components and hardly any in the third. For some people the overall impact of the triad may be quite severe whereas other people will learn to manage the affects without too much difficulty. The infinite possible combinations and permutations of the triad accounts for the huge breadth of the autism spectrum and the variety of children diagnosed with this condition (Hanbury, 2012).

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Figure 2.2 The Triad of Impairments (Wing & Gould, 1979)

2.2.2.2 Theory of Mind

Children with ASDs appear to be unaware of what other people are thinking and of what people are trying to make other people think (Happé, 1995). Therefore they miss out on essential social cues because they are unable to ‘read’ minds (Baron-Cohen, 2000). In 2002 this ‘mindblindness’ theory was extended and a theory of empathising- systemising was formulated to explain the apparent indifference of children with ASDs to the feelings of those around them (Baron-Cohen et al 2005).

2.2.2.3 Central Coherence

Frith (1989) coined the term central coherence to describe the force which pulls large amounts of information together in order to see the bigger picture. Weak central coherence is therefore understood as ‘a lack of a drive for meaning’ (Frith, 2003, p 152). Happé (2005) notes the central coherence theory can explain how good performance will be achieved by children with ASDs on tasks that require attention to detail but results may be poor on tasks that require recognition of global meaning. For this reason children with autism can recognise the identity of familiar faces from a part of an image but fail to pick up on context clues when reading. Weak central coherence also accounts for the piecemeal fashion that children with autism acquire knowledge and the unusual cognitive profile presented by many individuals. Caregivers may observe the lack of

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central coherence in the narrowed interests of children with autism, in the way that they are unable to generalise skills or in the ‘islets of ability’ that they sometimes display (Hanbury, 2012).

2.2.2.4 Executive Dysfunction

The term executive function is used to describe goal-directed behaviours (dealing with obstacles in gaining a goal). This category includes a number of skills such as flexibility, planning, inhibition, organisation, self-monitoring, goal setting and working memory (Ozonoff et al, 2005). Children with ASDs can appear to be disorganised and have a total disregard for the school timetable or the completion of tasks but, paradoxically, may develop an obsession with ritual and routine. Supportive materials including written lists of instructions, symbols and images can be used to help them, as they tend to be less overwhelmed by a complex task when it is presented as a series of small steps (Hanbury, 2012).

2.2.2.5 Joint Attention

What distinguishes children with ASD from typically developing children is not so much the fact that they do not interact with others but rather the ways in which they interact. For instance, they may approach caregivers with requests, make occasional eye contact and even take part in games taking turns but they do not tend to share their achievements and their interests with others and/or conversely they do not share in the interests of the people around them. In other words they do not share attention jointly with others (Whiteman & DeWitt, 2011). Joint attention refers to the ability of young children to coordinate their visual attention with another individual in relation to some object or event and associated skills include monitoring or directing the focus of attention of another person through pointing, gestures and gaze monitoring (Hanbury, 2012). Deficits in joint attention can lead to the early onset of a dramatic reduction in the tendency of children with ASDs to initiate episodes of social sharing with other people (Mundy & Burnette, 2005). Research indicates that joint attention is critical for acquiring oral language, deciphering other people’s communications and nonverbal facial expressions, learning through observation, developing empathy and understanding the minds of others (Whitman & DeWitt, 2011). This in turn can affect not alone

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language development but pretend play and their ability to understand the relations between stimulus and reward (Bigelow et al, 2004; Dawson et al, 2004).

2.2.2.6 Sensory Processing

In recent years difficulty in processing sensory information has become recognised as a further defining feature of ASD (Hanbury, 2012) although the role of perceptual abnormalities in causing autistic behaviours have not been systematically investigated and therefore requires further investigation (Bogdashina, 2003). Most children with ASD have unusual perceptions of sensory input and perceive everything as it is without interpretation or understanding ie ‘literal perception. Some individuals have problems in filtering sensory stimuli which may distort their perception so that they experience heightened sensory sensitivity (Grandin, 2006; Attwood, 2007) or hyposensitivity (Delacato, 1974). Some people may acquire compensatory strategies in order to cope with excess sensory information. When their brains become overloaded with sensory input this places them in a state of arousal and stress. Some may also have specific sensory dislikes such as the smell of food, noise of a dog barking, etc. Anxiety can escalate in sensory-rich environments such as supermarkets, playgrounds and classrooms. Their anxiety can be triggered when they receive specific input which they dislike eg smells and their responses at such times include ‘fight or flight’, emotional outbursts or the children concerned may appear ‘on edge’ (Bogdashina, 2003).

2.2.2.7 Personal Autobiographical Memory

A lack of ability to reflect on their own thinking means some children with autism have difficulty relating personal events but yet can recall many particulars about these same events as if they were observers of what was happening (Jordan & Powell, 1995).

2.2.3 Individualisation

The effects of autism can vary from mild to severe and the intellectual ability of the children can range across the spectrum from gifted to severely intellectually challenged (Baron-Cohen, 2008). Children with ASDs also present with a variety of cognitive, emotional and social capabilities (Mitchell, 2008). Evidence also suggests that children with ASDs have a visual learning style (Kuttler et al, 1998; Grandin, 2006), interpret

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sentences literally (Smith, 2003; Gray, 2004), display good visuo-spatial skills that do not involve language (Wing, 2002), and have a short attention span (Frith, 2003). Moreover children with ASDs often focus on irrelevant stimuli and show no apparent interest in what is going on and may have an outburst of aggression or self-injury with little or no warning. Without the cognitive flexibility to understand and process new events children can be easily thrown into meltdown (Baker, 2008). Caregivers, who are best placed to know the children’s particular requirements, need tools which are flexible and adaptable to cater for the idiosyncratic and individual nature of each child’s difficulties.

2.2.4 Learning Stages

Smith (2003) maintains that most children diagnosed with ASD are keen to do what is right and to behave in socially appropriate ways, if only they knew what they were. Whereas most neurotypical children seem to acquire basic social skills (initiating conversation, turn taking) quickly and easily through experience, imitation and by trial and error, children with ASD have to be taught these skills directly before they can be successful socially. Social interaction skills are learned and mastered through practice and performance by learning the sequence of steps in a new task and repeating those steps until a level of automaticity is reached (Bellini, 2008).

Social skills acquisition should be viewed as a continuum with children progressing from novice to mastery through three learning stages as follows:

 At the novice stage children require a great deal of cognitive effort and attention to complete a task

 At the intermediate stage children become more independent with the task but still need a great deal of cognitive energy to complete it

 At the mastery stage children can complete the task with little cognitive energy

At each of these stages the learner displays certain characteristics as illustrated in Table 2.1. Skills that are mastered may require additional instruction so caregivers will need to continue to teach children how to perform the skills better and provide them with opportunities to practise and perfect each skill (Bellini, 2008).

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Table 2.1 Stages of Skill Acquisition (Source: Building Social Relationships by Bellini, 2008)

Learning Stage

Characteristics of Learner

Novice 1. Exerts a great deal of cognitive effort to complete task

2. Vulnerable to distraction

3. Requires assistance to complete task

4. Makes frequent errors

5. Completes tasks slowly

Intermediate 1. Becomes more independent but still requires a great deal of

cognitive effort to complete

2. May hesitate between steps of the task, as she attempts to recall the

procedure

3. Performs tasks inconsistently

4. Makes fewer errors than novice learners; fluency is increased

5. Requires instant feedback on task performance

Mastery 1. Completes tasks independently with little cognitive energy

2. Is able to complete multiple tasks at the same time

3. Does not hesitate between steps of a task

4. Fluency is significantly increased

5. Typically performs errorlessly

6. Able to complete tasks across various settings and persons

7. Adapts performances to environmental demands

2.2.5 Learning Styles

The way an individual approaches learning and studying is known as his/her learning style or preference. There are a number of instruments available for assessing people’s learning preferences including the VARK system which classifies learners into four groups: visual, aural, read/write and kinaesthetic (Fleming & Mills, 2002; Fleming & Bonwell, 2008) (Appendix II). Nowadays many educational psychologists are sceptical about the value of learning preferences and maintain that learners, especially those who have difficulty learning, prefer to learn in a certain way because they have no alternative. For instance, children with autism may choose pictures because they have a difficulty comprehending the written word due to their weak central coherence (Woolfolk et al, 2013).

For many years researchers examined individual differences in ‘styles’ – cognitive styles, learning styles, problem-solving styles, thinking styles, and decision-making styles. This work can be divided into three traditions: a) cognitive-centred styles assess the way individuals process information by being, for instance, reflective or impulsive

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in responding; b) personality-centred styles assess more stable personality traits such as extroverted versus introverted; and c) activity-centred styles which assess a combination of cognition and personality traits that affect how individuals approach activities eg surface-processing or deep-processing. Mayer & Massa (2003) conducted a study into the distinction between visual and verbal learners with a focus on learning from computer-based multimedia which revealed that students may have a preference for learning with pictures but their cognitive spatial ability (if low) could make using pictures for learning less effective. Spatial abilities may also be important when it comes to learning from static pictures but may matter less when animation is used to aid learning (Woolfolk, 2013).

2.2.6 Language

A language may be defined as a system of communication which relies on symbols that can be expressed acoustically or graphically. One learns a language mainly through listening to users of that language. Delay in the acquisition of language may be caused by hearing deficits and delay in the use of language to communicate by motor deficits, not uncommon in individuals with autism (Tantam, 2013). Language deficiencies are in fact a core diagnostic characteristic of ASD with many children in this group failing to reach normal milestones in speech development (Appendix III). There seem to be critical periods for speech and language development in infants and young children when the brain is best able to absorb language. If their condition is not diagnosed at an early stage children may not be exposed to language during these critical periods and consequently they may experience communication problems later. As babies grow they first recognize important sounds in their environment (such as their mother’s voice) and then begin to sort out the speech sounds that compose the words of their language so by six months they should be able to recognize the basic sounds of their native language (NIDCD, 2014).

Moreover development of language can vary considerably among children who have been diagnosed with ASD (Whitman & DeWitt, 2011). Studies have shown that almost half of children in this group do not speak or only utter simple sounds (Heward, 2009) while children at the higher functioning end of the spectrum may develop quite complex language skills (Whitman & DeWitt, 2011). The use of language is rarely divorced from communication for the choice of words or phrases, or the tones of voice or stress

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patterns with which statements are made are often influenced by nonverbal communicative demands as well as purely linguistic ones (Tantam, 2013). It is quite often the case that children with ASDs tend to use language to get their needs met when they feel it is either the only way or the most efficient way (Siegel, 2003).

2.2.6.1 Expressive Language

Many children with ASD can learn to request and label items (Heward, 2009). However children may present with disorders of language expression despite having a normal understanding of language. This may be the result of impaired coding of language in which case language-based thinking is also affected, or of translating language into appropriate movements (articulation disorders such as stuttering) (Tantam, 2013). Sometimes their language may be marked by immediate echolalia (verbatim repetition of what people around them have said) or by idiosyncratic phrasing or usage (Janzen, 2009).

2.2.6.2 Receptive Language

Children with delayed use of speech may also have a delayed understanding which could indicate that their language processing is selectively impaired in comparison with their other cognitive abilities (Appendix IV). This is termed specific language impairment and is often associated with grammatical errors but errors of word meaning may also occur (Tantam, 2013). Consequently many children may learn to read and spell without formal instruction but they are unlikely to attach meaning to these words on their own (Janzen, 2009). Moreover they may experience processing-speed delays and this can also cause them to miss some of the message and hinder them from reaching the same comprehension milestones as typically developing children (Siegel, 2003). Children in this group also tend to process verbal information literally and thus often have difficulty in understanding abstract concepts, idiomatic expressions or humour (Heward, 2009). For this reason it can be hard for them to compare or contrast ideas, make judgements, adapt rules or evaluate alternative options (Janzen, 2009).

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2.2.7 Special Interests

Some children with ASDs become intensely interested in unusual subjects (eg light bulbs, dinosaurs, train timetables etc) almost to the point of obsession and will talk non- stop about these topics at the risk of boring their listeners. Their development of spontaneous usage and expressive language are often tied to talk around their special interests (Siegel, 2003). Sometimes caregivers can use these fixations to motivate a child to remain focused on a lesson. Special interest areas (SIAs) can function as the irresistible bait to lure the children to acquire academic and/or social skills (Heward, 2009). For example, the Power Card strategy (created by Gagnon 2001) is a visual aid that uses a child's special interest to help him understand social situations (Henry & Myles, 2007). The card contains a picture of the special interest and a brief three to five- step summary of the solution. When children with ASDs are allowed to discuss and explore their special interests in an environment created specifically to share those interests such as clubs and workshops their desire to interact and socialise can increase (Henry & Myles, 2007). Other programs such as Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH) assess a child’s interests as part of their holistic approach to teaching children with ASDs.

2.3 Assessment Tools

Without the professional services of suitably qualified personnel a diagnosis of ASD cannot be reached. However there are some tools available which can help caregivers to