Autism Spectrum Disorder
Given the uproars of laughter from the other children in response to some of Jacob’s actions, the teacher was convinced that Jacob did this to make her look foolish and to get attention from the other children. On numerous occasions (including the clothing removal episodes), it was necessary to take him to the infirmary until his mother could be summoned to calm Jacob down or bring a different set of clothes to school because Jacob refused to put the original clothes back on. With his mother present, Jacob put on the change of clothes and returned to the class without further incident. The fact that Jacob cooperated with the mother and put the new clothes on further reinforced in the mind of the teacher that the original episode was deliberate.
A CRITICAL THINKING AND QUESTIONING PAUSE
Think back to the critical thinking model we outlined earlier in this text.
What error does the teacher appear to be making by assuming that Jacob’s
“problem” behaviors are directed toward her? The subtitle of this casebook also provides you with a solid hint. That’s right! The teacher is looking only at the behavior and assuming that the behaviors are the problem. In fact, however, Jacob’s behaviors are more likely to be symptoms of a more severe underlying problem. What critical piece of information does the teacher apparently not take into account when assuming that the clothing removal is designed to make her look foolish?
Reread the paragraph just before this pause. When are these episodes most likely to happen? Yes, when the teacher is a substitute. Perhaps the clothing removal is an expression by Jacob of his displeasure over the change in teachers. It comes as no surprise that Jacob would respond more positively to the efforts by his mother to get him to put his clothes back on than a teacher who is also a stranger. This displeasure with change can be an important part of Jacob’s illness and can be an important thing to con-sider during treatment. We will, of course, revisit this “need for sameness”
as we discuss the details of Jacob’s case.
On most days, Jacob was diligent in working with materials at his seat, especially when they involved drawings or pictures. He was also attentive dur-ing school activities that involved music. At other times, somethdur-ing as simple as a ringing school bell or sudden public address announcement would upset Jacob greatly. He appeared to have a very short attention span during orga-nized group activities like gym class. Most of the time when another child approached him, Jacob moved a good distance away. His gym teacher has given up trying to interest Jacob in the cooperative games that take place in that class.
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In the school cafeteria, Jacob sat alone, did not interact with other children (or anyone else), and when finished eating, often simply got up and walked back to the classroom on his own, before lunch period is over. After trying to stop him several times to no avail, his teacher began permitting this since all Jacob did while the others remain at lunch was sit at his desk drawing or reading.
Jacob’s disinterest in being with other people was particularly evident during a recent field trip to a farm. Leaving the classroom to board a bus that would take the students to the farm, Jacob broke off from the others and went instead to a different bus, which happened to be the one he normally rode to school. Jacob cried and resisted strenuously when he was taken by the hand and led firmly to the bus that was to be used for the field trip. Think back to the critical thinking pause just a few paragraphs ago. Could Jacob’s reaction be another example of a resistance to change?
Once at the farm, the teacher was surprised by his reaction. On the basis of Jacob’s thorough effort to learn and demonstrate accuracy in identifying differ-ent farm animals depicted in pictures, she expected him to enjoy watching and petting live animals. However, he refused to approach any animals during the visit and spent almost the entire time playing with the pump handle at a well.
When it came time to leave, he again resisted getting on the bus and returning to school.
Jacob’s problems at school finally came to a head when, with no warning, he deliberately broke a classroom window and immediately began arranging the shards of glass into a pattern, as though they were pieces of a jigsaw puzzle. This incident was the last straw for his teacher, and the next day her referral report was sitting on the school psychologist’s desk.
The Diagnostic Interview
Jacob’s mother came to school and accompanied him to Dr. Gray’s office. When prompted by his mother, Jacob shook hands in a perfunctory manner, looking away and saying nothing in response to her greeting. Dr. Gray noted that, physi-cally, there did not appear to be anything wrong with Jacob. He was of average weight and height for his chronological age. However, she also noticed that once seated, Jacob seemed oblivious to the presence of his mother and the psycholo-gist a few feet away, and was content to draw numbers, letters of the alphabet, and simple geometric figures on a pad of paper. Dr. Gray began by describing what she knows of Jacob’s difficulties from reading the teacher’s written report.
After hearing the psychologist’s summary of Jacob’s behavior problems at school, Mrs. T expresses some surprise at the extent of his problems but acknowl-edges that Jacob, her youngest, has been by far the most challenging of her four children to parent. Although her pregnancy and birth with him were normal, and he experienced only the typical run of illnesses during infancy, she noted that from the beginning he was not “cuddly” as her first three children had been.
He almost never looked directly at her, and he squirmed vigorously when she held him close during feeding. When he became upset, Jacob rarely cried and did not respond to hugs when it seemed that he might need to be comforted.
If anything, receiving hugs seemed to make him more upset; he would f lail his arms about and scream until put back in his crib. Until she learned to play his favorite music at bath time, Jacob often resisted his mother’s efforts to bathe him.
Mealtimes were also a frequent problem because, for a long time, he insisted on drinking from the same plastic cup and refused f luids when they were offered in anything else (another example of a need for sameness and of resistance to change).
As a toddler, Jacob continued to ignore his mother’s efforts to interact with him. He actively resisted sitting on his mother’s lap and looking at the pages of a book while she read to him, which was something all three of his older siblings had seemed to enjoy. He was also very slow to learn to use any recognizable language. Most of his verbalizations took the form of grunts, or every once in a while, a sudden burst of raucous laughter. Jacob did not begin to speak recogniz-able words until he was nearly 4 years old, and even now his speech is not nearly as f luent as that of most 7 year olds.
By the time Jacob was 3, he had begun to spend lengthy amounts of time in a variety of perseverative (that is, tediously repetitive) activities, such as rolling a ball back and forth, turning light switches on and off, and later f lushing the toilet many times in succession. He also learned to ref lect light coming in the window of his room using a small mirror and would become engrossed in mov-ing the patch of light around the room for an hour or more at a time. Most of his enjoyment came from playing in this fashion with various inanimate objects. He would stack blocks on top of one another or line up small toy figures in solitary play that would often last an entire afternoon. Once when placed on the seat of his sister’s tricycle, Jacob squirmed to get down, but later after someone else had turned it upside down on the ground, he amused himself by spinning the wheels with his hand.
In contrast to his marked interest in certain inanimate objects, Jacob was rather indifferent towards people. He paid no attention whenever anyone came or left the house, whether a family member, adult stranger, or prospective playmate. He seemed happiest when left alone and became upset if interrupted while engaged in one of his perseverative activities. However, if the interruption ceased, Jacob would resume what he had been doing and seemed to forget the interruption entirely. Although these peculiarities made Jacob different than his siblings, his mother noted that given the time her other three children required of her, she often felt relieved that Jacob made relatively few demands on her attention.
Other peculiarities were not so easy to tolerate. On one hand, Jacob learned to like throwing things on the f loor, especially if they bounced or made a noise.
On the other, loud noises that he did not anticipate—such as a vacuum cleaner, barking dog, or loud traffic—usually upset him. He nearly spoiled the only
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birthday party he was ever invited to by his intense reaction to the noises gener-ated by party horns and popping balloons.
From his parents’ standpoint, he was also very stubborn. For example, their efforts to toilet train Jacob were almost completely ineffective until he reached 5 years of age. At one point, his mother became concerned enough by these and other problems to describe them to his pediatrician. The pediatrician thought Jacob was probably just developing more slowly than the other children, or might be showing signs of mental retardation. Just one day prior to his fifth birthday, however, Jacob took off his diaper without saying anything, put on a pair of the underwear his mother had kept in his dresser drawer, and never used a diaper again.
In terms of more positive features, Jacob showed an intense interest in draw-ing, colordraw-ing, and working with jigsaw puzzles. His mother once found him putting a jigsaw puzzle together with the picture side face down, and was sur-prised when he completed it successfully in about the same amount of time it would have taken him to do it face up. He also demonstrated an unusually good memory for pictures and names, quickly learning the names of all US presidents in a picture book.
In gathering this information, Dr. Gray’s interview with Jacob’s mother lasted almost 2 hours, yet during all this time, Jacob had not become restless or bored.
Dr. Gray decided to see if Jacob would talk to her. As she moved her chair over to where he was busy drawing and began speaking directly to him, Jacob abruptly turned his chair 90 degrees away from Dr. Gray so that he was look-ing off to the side. As Dr. Gray gently prodded him to converse, Jacob began to respond in a perfunctory manner and showed no change in facial expressions.
Increasingly long pauses separated her questions and his answers, and Dr. Gray eventually noticed that Jacob was looking steadily at a chart on the wall of her office that included pictures illustrating various units of measurement. She invited him to move closer to the chart and, after a few moments, began asking him about it. Jacob was able to respond very knowledgeably to simple questions about metric measurements (meters, liters, kilograms) displayed on the chart. As the questions continued, however, Jacob started showing signs of concern whether his answers are correct. He became confused when Dr. Gray pronounced “liter”
in a way that rhymed with “meter” and abruptly turned away.
A CRITICAL THINKING AND QUESTIONING PAUSE What diagnoses should Dr. Gray be considering at this point? Although you already know this is a case about autism, such a diagnosis would not be immediately apparent, especially in this case. Autism usually involves some fairly extensive speech challenges that do not appear to be evident in Jacob’s case. Jacob’s ability to learn rapidly from the chart on Dr. Gray’s
wall and to answer questions about that information suggests that his intel-ligence is at least of a modest level. But nothing that Dr. Gray has uncovered by interviewing the mother corresponds with the teacher’s thoughts about oppositional defiant disorder, conduct disorder, or even ADHD. In order to reach conclusions about the nature of Jacob’s behaviors, Dr. Gray still needs to gather more information and may need to consult with other specialists before making her decision.
Gathering the Data
Dr. Gray escorted Jacob to a play area and invited him to draw while she con-tinued interviewing his mother. Accurately diagnosing a mental disorder in a child requires a careful, detailed history. Dr. Gray asked Mrs. T to summarize Jacob’s significant childhood illnesses (especially fevers and infections) and also questioned her about certain other aspects of his behavior. For instance, Dr. Gray asked for examples of when Jacob’s play has shown elements of imagination or creative fantasy. Mrs. T recognized the significance of this question since she could not come up with any examples. She could not recall any instances of Jacob role playing, or even attempting to play with a toy in a fashion other than that for which it was designed (such as using a broom handle and pretending it is a horse to ride).
Noting the episodes of disrobing at school, Dr. Gray asked whether Jacob ever seemed overly sensitive to touch. Mrs. T agrees that he did and noted that Jacob liked to keep doors and windows closed, that drafts of wind (e.g., sit-ting by an open window while riding in the car) bother him greatly. She also mentioned that he hated to be bundled up in cold weather. Dr. Gray then asked about Jacob’s tolerance for change in his environment. You will recall several problematic behavior episodes at school as Jacob responded negatively to changes in schedule or buses.
Jacob’s mother explained that he has little tolerance for change and offers a striking example. Once Jacob became upset when his father walked into the room and picked him up to give him a hug. Jacob made loud grunt-like vocal-izations and would not calm down until his father put Jacob down, pulled his glasses from his shirt pocket and put them back on. Apparently his father had removed his glasses to clean them before walking into the room. Even this minor change in Jacob’s environment was distressing to him.
After over two and a half hours, the interview ended and Jacob and his mother left. Ref lecting on what she has learned, Dr. Gray noted that Jacob’s problems were evident at a very early age and showed themselves as failures to demonstrate the normal developmental sequence or progression through which most children proceed. This led her to suspect some form of developmental disorder. The specific diagnosis she was leaning towards was Autism Spectrum
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Disorder. Autism is not a single, homogeneous disorder but rather a collection of syndromes involving a constellation of symptoms that can vary in severity.
Confirming a diagnosis of Autism Spectrum Disorder usually requires input from other specialists, such as a pediatrician, a professional (often a psychologist) who specializes in developmental and learning disorders, and a speech/language specialist.
Dr. Gray arranged for consultation with these other professionals. Jacob received a speech and hearing evaluation from the school’s speech therapist, who used the Peabody Picture Vocabulary Test to assess his verbal comprehension. In a later session, Dr. Gray administered the Wechsler Intelligence Scale for Children.
Jacob’s overall IQ score was 88, which is in the low normal range. However, his performance IQ was significantly higher than his verbal IQ, suggesting that therapy to strengthen his language skills needed to be included as part of his treatment. Given his functional deficits, if his IQ had been below 70, it might be appropriate to diagnose him with Intellectual Disability (previously called Mental Retardation) as well as Autism Spectrum Disorder. To evaluate Jacob’s overall functioning systematically, Dr. Gray also conducted separate structured interviews with Mrs. T and with Jacob’s teacher, using the Vineland Adaptive Behavior Scales. Regarding the severity of Jacob’s disorder, Dr. Gray tentatively gave him the least severe rating (Level 1—“Requiring support”), and added that intellectual impairment is absent, since his IQ is in the low normal range.
The Assessment Model
Jacob had difficulty staying connected to the social world. Although his behav-iors gave the appearance of withdrawing or disconnecting from the social world, it is probably more accurate to state that he never fully connected to it in the first place. Persons suffering from Autism Spectrum Disorder may stare vacantly, ignore other people in their social environment, and may exhibit stereotyped (repetitive) movements, such as rocking back and forth.
One of the key problems Jacob displayed is impairment in one-to-one inter-action. He also showed restricted, repetitive patterns of behavior and interests.
Although his drawings of letters and other concrete images were often much better than those of his peers, his efforts in this regard were perseverative and showed little spontaneity or creativity. Jacob has not drawn objects he cannot see, thereby showing little use of his imagination. He also showed little to no use of imagination or fantasy when he plays. Again, his play appears to be persevera-tive and not designed for “fun.”
It is very typical of persons with autism to show delayed use of language.
Jacob’s parents took note of his obvious slowness at demonstrating language in comparison with his older siblings. In contrast to most children, Jacob never learned to point to objects in the environment, although he was able to take his mother’s hand, lead her to an object he wanted, and push her hand in the
direction of the object (a toy, glass of water, etc.). Jacob tended to react to physi-cal restraint by vigorously pushing the other person’s hand or arm away, but he never learned simply to ask that it be removed. His first functional use of language was simply to respond silently (but appropriately) to simple, concrete instructions. Later, when he himself began to speak in a rudimentary way, the rhythms and cadence of Jacob’s voice were somewhat rigid and artificial.
By the time he entered kindergarten, it was clear that Jacob could understand language and communicate his needs in a basic fashion, but the words he used tended to have very literal meanings for Jacob. For example, to Jacob putting something “down” always meant putting it on the f loor. By age 6, Jacob’s speech was more functional (such that he was more effective in communicating his wants), and adequate rote learning skills enabled him to acquire basic school-related information, such as letters of the alphabet and the names of colors.
However, Jacob still exhibited social difficulties, including disinterest in others and a strong preference for rigid routines.
Jacob’s gym teacher assumed that his disinterest in participatory social activi-ties and sports involving other children ref lected a short attention span. That assessment, plus Jacob’s disregard of codes of conduct at school, led his teacher to suspect ADHD. A child with ADHD is distractible, impulsive, and may be learning disabled, all of which seem to apply on occasion to Jacob’s behavior at school. However, a child with ADHD is easily angered, and the anger persists.
Jacob, by contrast, does not get angry very often and will cease being angry almost immediately after whatever aroused him is removed. In autism, there is often one or more unusual interests or special preoccupations (such as music or drawing), a characteristic that tends not to be found in children with ADHD.
Asperger’s disorder is another syndrome that entails repetitive patterns of behav-ior and impaired social functioning. Although it resembles autism with respect to the individual’s social aloofness and peculiar interests, and in DSM-5 is one of the diagnoses falling under Autism Spectrum Disorder, Asperger’s disorder entails nor-mal language development and average or better intellectual functioning.
Treatment Considerations
Because autism is a “spectrum” disorder (which means that it seems to cover a group of different symptom patterns and may have more than one cause), no single treatment is effective in all cases. With Jacob, as with most other individuals who have autism, there are multiple symptoms and a variety of dif-ferent interventions that are used simultaneously. The most important of these are behavior modification (with a once-per-week session attended by his parents to help them keep up with the program and maintain use of the procedures at home), and speech/language therapy.
Although antidepressant medications are sometimes used to reduce aggressive-ness, and amphetamines are sometimes prescribed for symptoms of hyperactivity,