Autistic Spectrum

Autistic/PDD Spectrum Disorders

I have a special interest in children whose developmental problems fall in the "spectrum" of Autism, Pervasive Developmental disorder (PDD), and Asperger's Disorder. We must be extremely careful about how we use these diagnostic labels. At one time, the term "autistic" was reserved for the most severely impaired people. However, many people noticed that some children have some but not all characteristics of autism. Over about the past 20 years, the definition of autism has been expanded into a broad "spectrum." This broader definition can contribute to misdiagnosis. This has increased the need for careful evaluation.

What is a Pervasive Disorder?

These disorders are called "pervasive," because the symptoms "pervade" (extend to, or impair) all aspects of the child's life. In contrast, "specific" developmental disorders are restricted to one or sometimes more than one specific area. For example, a child with developmental delays (even serious delays) in speech and fine motor skills does not have a "pervasive" disorder. Often the social and emotional development is the most seriously impaired and needs intensive work as early as possible.

Some prominent researchers and clinicians prefer to avoid the PDD, Autistic, and Asperger's labels because they can be used in imprecise or pejorative ways. Stanley Greenspan has included such disorders in his broader category of Multi-System Developmental Disorders (MSDD). Others have used a similar term, Multiple Complex Developmental Disorders (MCDD). Ivar Lovaas, Ph.D. has developed an intensive behavior therapy regimen for autistic spectrum disorder. Dr. Lovaas has also advocated caution in applying these diagnostic labels.

Diagnosis

Diagnosing these disorders must be done extremely carefully. It is most important to understand the child's developmental profile of strengths and weaknesses. It is also essential to take a detailed developmental history. One of the primary criteria for this diagnosis is severely impaired capacities for attachment and social relationships. Thus, it is critical to observe the child in interaction with parents and others who know him well. Many children who may look impaired in some settings (especially at school) can show great warmth and attachment with people whom they know well. Such inconsistency can be the source of misdiagnosis, especially when an evaluation is done in school or another setting where parents and child are not made welcome, helped to relax, and carefully observed. Unfortunately parents and child can be subjected to prolonged stress by the diagnostic process, at a time when they are extremely vulnerable. It is the responsibility of professionals to reach out and understand what the family members have endured, and to help them with this process.

The professional must take the time to get to know these children in detail. Their behavior is often hard to interpret. For example, children who withdraw and do not like to make eye contact are sometimes thought to have autistic spectrum disorders. However, there are several reasons children may behave in such a manner. These reasons can include sensory overload and inability to process information. Disorders of language and auditory processing can also cause children to behave in ways that seem "autistic" to some people. Nonverbal learning disabilities can also cause this type of behavior.

The professional must take the time to get to know the child's parents and family. This includes helping parents organize their reports of the child's development, behavior, and reactions to different kinds of stimuli. It also includes helping parents with the stress involved in taking care of a child who is difficult to understand, and whose behavior may be difficult to deal with. It includes understanding the sibling relationships and extended family relationships that can be resources for the child. Finally, it includes understanding the needs of the child for education and child care, and how these can best be met.

Treatment

Multi-system disorders require more than one type of intervention. A child does not usually need all possible treatments at the same time. Prioritizing and sequencing the treatments is an important job. Initially, the evaluation process should be a source of support and clarification for parents and child. Another intervention during the evaluation is integrating conclusions and recommendations from different fields. Parents can feel overwhelmed by reports from occupational therapist, language therapist, physician, psychologist, and, educators. Parents often also need an experienced person to advocate for them and for their child.

A home program of parent-child work This program gives parents an active role which enhances all other forms of education and treatment. I can help parents set this up and maintain it. I do not, however, have training in the specialized Lovaas type of home treatment.
An appropriate educational placement is also essential. Children with these developmental disorders can be difficult to place. They often do not fit in any of the school system's categories. A strong educational advocate can make a tremendous difference. An individualized educational plan is even more important for these children than for others, because they can have such unique combinations of strength and weakness.
Developmental therapies such as occupational therapy (including sensory integration therapy) and language therapy are usually essential. Sometimes these therapies happen as part of the educational placement; often they must happen privately.
Regular developmentally based psychotherapy, which I can provide, is a specialized use of play therapy and developmental insights to help children "climb the ladder of development." It can help parents with their questions about managing the child's behavior and carrying out the home program. These sessions can be individual for the child or include parent and child together.
Medication can have a positive role, though it is important not to see this or any other single treatment as a panacea. I have worked with child psychiatrists and pediatricians in evaluating the success of medication treatment. The type of medication used will depend on the individual child's profile of behavior and development. Medication goals often include enhancing attention and concentration, and decreasing repetitive behavior.
Behavioral treatment can also be helpful in helping children acquire specific behaviors and skills. This can include parent training and reward programs. Some children need behavioral programs designed for specific strengths and weaknesses. For example, those who have little language may need pictorial, step-by-step approaches to learning skills of daily living. In addition, some children may benefit from the very intensive behavioral help developed by researcher and advocate Ivar Lovaas. This therapy applies behavioral conditioning principles and requires careful organization by a professional trained in these techniques. It requires many hours of practice and several therapists.