For many families the end of summer can be filled with worries of how their child will deal with returning to school, particularly for children with autism and other special needs. After a few months of a new summer routine, or a lack of a consistent routine, and for many the lack of demands (e.g., getting up early in the morning, dressing before a certain time, doing homework) this change can be dreaded.

Consider the changes the new school year will bring and try to prepare in advance for these changes by forewarning and practicing as much as possible. These new anticipated changes should be coupled with what we know of many children with autism and other developmental delays such as their tendency toward structure, routines, pictures and often music;  Also what we know of children with autism regarding the presence of organizational difficulties, distractibility, and difficulties with generalizing. Recommendations for preparing for the upcoming changes the school year may bring may include the use of routines, visual supports including picture or written schedules and new rules, as well as stories about what can be expected including more specifically:

• Bed time and awaking—take the 1 or 2 weeks before school starts to gradually require your child to get to bed earlier and up earlier in the morning. You may try putting your child to bed at the time that will be required once school starts, or slowly move back bedtime a bit each night toward this ultimate school-time bedtime.  A new bedtime or awake time may need to be discussed directly with your child, and written rules and new routines may be drawn up and posted (e.g., 7:20 prepare for next day, 7:30 brush teeth and put on pajamas, 7:45 story time, 8:00 lights off).
• Morning and nighttime routines—bedtime may now include setting school clothes out for the morning or packing a backpack. If your child is bothered by tags and other nuances within certain clothes make sure to make necessary adjustments now to eliminate distractions while they are expected to attend in class. As mentioned with regard to bed time and awaking, visual supports may be used.
• Meals and naps—try to align lunch time with the time the school will have lunch and determining what foods your child can bring to school and actually eat there. If naps have occurred during the upcoming school time hours you can also attempt to move naptime up or back and limit it to the 45 or 60 minutes they will be limited to at school.
• Homework—homework may now return or become a new daily routine required of your child every afternoon. While not necessary to provide your child with practice homework in advance, you may begin to limit access to preferred activities or items to use these as rewards for when homework is present. You might begin to make television or computer time only available after dinner, and thus when school starts, also after homework. And while you may not present them with worksheets now you may set aside some time in the afternoon to sit down and read or do some puzzles or other table top tasks that require sustained attention as homework will. Practice these tasks during time when homework would generally be required and begin to set up reward systems in which reinforcing items and activities follow these tasks.
• New school and/or new classroom—for those children where change is difficult, bringing them to the new school or new classroom, even showing them in advance pictures or simply talking to them about what they may expect can be comforting and a big relief. Many teachers are on campus preparing for the new school year a few days in advance and are often very understanding of specialized needs your child and family may have related to these changes. Take pictures of your child’s new school, new classroom, new teacher, etc. to use to review and discuss the upcoming changes and provide them with some information on what they can expect to decrease any anxiety. You may even get a few names of new students who will be in your child’s class to set up a few play dates in advance of the new school year so when school starts your child has a few familiar faces to greet.
• Associate school with fun new things– having a new backpack, lunch box, new pair of shoes or other items that are reserved for school may make getting up and going off to school that first day or week that much more exciting. A new school year is a new beginning and starting off with some new items to bring along that are rewarding and desired for your child may associate a new school year with desired activities.

Punishment is widely used in our society. Punishment can be seen in imprisonment, late fees, speeding tickets, and detention all for not following socially acceptable rules. By definition, punishment is anything that follows a behavior that leads to the decrease of that behavior in the future. This may include adding something to the environment or situation such as giving detention or issuing a parking fine. It also includes removing things from the environment of situation such as taking away dessert after dinner as well as the popular “grounding” (e.g., no television or computer, cannot go over friend’s homes on the weekends).

If punishment is so widespread in our society then why do behavior analysts generally seem to frown upon punishment procedures and tout the benefits of reinforcement and reward procedures? Ensuring that one has exhausted interventions focused on reinforcement before utilizing punishment procedures is even part of the guidelines for ethical conduct that behavior analysts must follow to maintain their certification. Punishment is in fact believed to have many negative and troublesome side effects that dissuade behavior analysts from using it.  This includes that punishment may:

• Elicit undesirable emotional responses—excess anxiety, guilt, and self punishment may occur as a result of punishment
• Model undesirable behavior—when parents and caregivers use punishment they are modeling for their children undesirable behaviors
• Increase escape and avoidance of those punishing them and the general punishment environment—those being punished often form negative associations with their punishers and as a result avoid them and those environments where the punishment occurs due to negative associations
• Increase the likelihood of the punisher increasing the intensity of their punishment—punishment can easily escalate to harm of others
• Not effectively reduce the problem behavior from occurring—while punishment may momentarily result in the problem behavior stopping, it has not been demonstrated to be effectively in decreasing it in the long-term
• Not teach the individual being punished  what to do—punishment sends messages about what behaviors are undesirable but neglects to highlight what behaviors are desirable

Why use reinforcement and rewards instead?

Behaviorists seek to control behavior just as effectively by using reinforcement to successfully avoid the problems and negative side effects of punishment, and in doing so, seek to teach an alternative to those undesirable behaviors.

By definition, reinforcement is anything that follows a behavior that leads to the increase of that behavior in the future. Like punishment this may include adding something to the environment or situation such as giving an allowance for chores, giving dessert for extra chicken nuggets for eating all ones vegetables, or letting your child stay up later for getting a good grade on a spelling test. Reinforcement also includes those things removed from the environment to increase a behavior such as fastening your seatbelt so the alert signal stops dinging, or taking some aspirin to get rid of a headache.

In attempt to decrease the amount of punishment a parent or caregiver use and increase their use of reinforcement behaviorists may ask parents and caregivers to reframe their approach. A reframe can start with a simple rewording. For example, a child is jumping up and down on the sofa, rather than yelling for them to stop, remind them that you like it better when they sit on the sofa and when they do sit or are sitting down tell them what a good job they are doing sitting, or happy it makes you to see them sitting on the sofa, or even tell them they are sitting so nicely they get 15 minutes of extra TV time before bed. Another example, a child is hitting their sibling, rather than taking away their time on the computer later that night remind them that if they want to play with the computer later that night they have to keep their hands to themselves and let an adult know if they need help resolving a problem.

Very often parents express concern for having to give their children rewards all the time. The goal of intervention should always include moving away from the need to consistently use such rewards. Behavior intervention generally works to require individuals to do more or go for longer without the reinforcement or reward. As behavior intervention is often used with children with autism and other developmental delays it is important to recognize that while a child may chronologically be 10 they may developmentally much younger at an age when children generally need more rewards. This thinning of reinforcement, or gradual decrease of reinforcement so that the desired behavior is maintained naturally within the environment is built within our school systems as well as many of our homes. When in preschool very few demands are placed, and if so are often short and  within the context of having fun such as signing during circle time, sitting to color or paint, and more often the day includes a lot of free play where children are allowed to run and climb on equipment, and play with toys of their choosing. As they grow older the number of periods of free play or even recess is decreased and more time is spent sitting at a desk completing lesser preferred work tasks. Within time a child has grown to an adult who goes to work weeks at a time before getting their reinforcement—a paycheck!

Reinforcement or rewards do not necessarily be big fancy expensive items continuously purchased. Instead some of the strongest and most effective reinforcement or reward systems are those that capitalize on naturally occurring reinforcement or rewards in the environment. This often requires parents and caregivers to reassess what are considered privileges. While it is nice that parents provide for their children many fun and engaging activities and preferred items, when television, computer time, video games, ice cream, and other sweets are freely available, parents may be missing out on opportunities to increase behaviors they desire in their children. At the most basic level, reinforcement and reward systems require parents and caregivers to take examine when their child already accesses preferred items and activities throughout the day and week and restructure so that these items generally follow non-preferred activities and demands where they may be struggling with their child. For example, if homework is a difficult time, making sure that watching television only comes after homework time, or even that homework is broken down into more manageable chunks followed by a bit of computer time after they complete each chunk. Or a preferred breakfast item like a more sugary cereal or blueberries with cheerios is provided when your child gets up and dressed without problem behaviors as opposed to getting plain cheerios should they have difficulties. Video games and computers only after they’ve taken out the trash or fed the dog. Or television time only after they’ve showered.

Such systems often require parents and caregivers to limit a child’s access to preferred items throughout the day. Doing so increases their strength, or makes them all that more powerful and thus leaves children wanting them more and thus more likely to engage in the behaviors their parents desire to receive reinforcement. Limiting access may be done most simply by setting up daily schedules—television only after they’ve gotten ready for school in the morning and are waiting for the bus to come and after dinner and bath time, or video games only after homework is done.

For practice…

• Practice “rewording” to increase the reinforcement you use with your child and decrease the punishment.
• Outline your child’s day complete with specific activities or routines and when they generally are permitted access to preferred items/activities and thus reinforcement. Mark off what routines are the most difficult for your child and/or you.

There were several significant stories over the past few months regarding new research related to autism. While the research findings might not have any immediate benefit to people with autism, the new knowledge could further the cause of understanding autism and might in the future lead to meaningful benefits to affected people and families.

Here are links to several interesting research findings and news stories:

• Children Conceived In Winter Have A Greater Risk Of Autism http://www.medicalnewstoday.com/articles/224314.php
• Diabetes, Hypertension, Obesity Linked to Autism http://tinyurl.com/3bzewz6
• Autism on the Rise, but Cholesterol May Help http://tinyurl.com/3v92zzl
• Early Identification of Autism is Essential http://tinyurl.com/435n7tv
• Autistic People have Better Perception of Symmetry http://tinyurl.com/3rejxg7
• Women Who Start Prenatal Vitamins Early Are Less Likely To Have Children With Autism http://tinyurl.com/4yxphzl
• Autism Brains Alike; Very Different From Normal Brains http://tinyurl.com/3ku5e68
• Functional Magnetic Resonance Imaging may Improve Diagnosis of Autism http://tinyurl.com/3slchhc
• Fever During Pregnancy May Cause Rise in Austim Risk http://tinyurl.com/3qy9n88
• New Clues to the Genetic Roots of Autism http://t.co/RxPDpq7

Studies have revealed that many parents report or observe initial concerns with their child’s development prior to the age of 3 (Chawarska, et al, 2007), with about a third of parents of children with Autism Spectrum Disorders (ASD) reporting having noticed problems before their child’s first birthday and 80% before their child’s 2^nd birthday (De Giacomo & Fombonne, 1998).

Despite parents reporting concerns early on in their child’s life and the standard for diagnosing a child with an ASD being just 18 months, on average children do not receive a formal diagnosis of ASD until between 4.5 and 5.5 years of age (National Center on Birth Defects and Developmental Disabilities, 2002). The importance of early detection lies in the ability to then provide children with ASD with early intervention services when the infant brain is more flexible or malleable and therefore able to more readily absorb and encode new information. While in 2007 the American Academy of Pediatrics recommended that all 18- and 24-month-old children be screened for autism, the effects of this have not yet been scientifically qualified. Until confidence in this early screening as a protective factor exists, parents will need to continue to be the primary advocate for their children.

When parents did report concerns prior to the age of 3, they overwhelmingly reported concerns with speech and language (71%) and social difficulties (61%) as opposed to medical problems and motor delays, or the presence of stereotyped behaviors (Chawarska, et al, 2007). When wary of an ASD diagnosis, parents should consider that ASD generally consists of not only delays in socialization and communication, but the presence of stereotyped behaviors. Overall, increasing ones knowledge of typical infant and child development is believed to be beneficial in detecting early signs of ASD.

Developmental regression was a noteworthy indicator. Regression has been found to typically occur between 12 and 24 months of age with 25% of ASD cases termed as “regressive” and regression overwhelmingly occurring in the areas of communication and socialization.

In addition to being aware of typical infant and child development, parents and professionals who interact with children and infants should be aware of the National Institute of Child Health & Human Development’s (NICHD) 5 Behaviors Signaling Need for Evaluation:

1. Does not babble or coo by 12 months

2. Does not gesture (point, wave, reach) by 12 mos.

3. Does not say single words by 16 mos.

4. Does not say 2-word phrases on own by 24 mos.

5. Has any loss of language or social skills at any age (i.e., regression)

Should a child demonstrate or not yet demonstrate such behaviors defined by NICHD or those further detailed below, formal or further evaluation is generally warranted.

Not only is it important to understand the specific behaviors and/or symptoms associated with autism, or Autistic Disorder, it is equally as important for parents and professionals to understand how autism is diagnosed, when it can be diagnosed, and some of the finer points of the diagnosis. Below are 6 commonly misunderstood or unknown factors related to receiving or securing a diagnosis of autism:

1. Autism can only be formally diagnosed by medical doctors, psychologists, and psychiatrists. These are individuals with training regarding the diagnostic criteria of autism and other disorders.
2. There is currently no medical testing available for autism which includes the absence of genetic, neurological, and blood-testing to identify individuals as having autism.
3. While there are no medical tests to diagnose autism, there are standardized screening tests that involve interview and/or observation of the individual and/or those familiar with the individual. Standardized screening tests generally focus on determining the likelihood that an individual has autism given the behaviors they do or do not engage in that are related to the diagnostic criteria of autism.
4. Autism is generally diagnosed through observation and interview during which assessors look to ensure an individual meets specific criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Interview concerns the individual’s history, particularly prior to the age of 3 as a diagnosis of autism requires that prior to 3 years old a delay in at least one area: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.
5. A formal diagnosis of autism cannot be given until the individual is 18 months of age in accordance with the DSM. While research has identified some possible indicators of autism prior to 18 months (i.e., placenta symmetry, accelerated head growth and the limbic system, relative  length of digits, brainstem abnormalities and neocortical malformations), diagnoses made prior to the age of 18 months are generally less predictive of a stable or reliable diagnosis of autism after the age of 3 and overall across time.
6. Just as one can receive a diagnosis they can “lose” a diagnosis or be re-diagnosed as no longer having autism or having another disorder. Not only do professionals sometimes misdiagnose individuals as having autism (or any other disorder), individuals can gain skills that may cause them to no longer meet full criteria for autism but instead to qualify for another related developmental disorder such as Asperger’s or Pervasive Developmental Disorder, Not Otherwise Specified. A diagnosis of any sort is simply a set of criteria with specific time lines, etc. As an individual gains new skills some of their defining characteristics of autism may no longer be present.

The global awareness of Autism has grown significantly during the last decade and continues to do so.

April is Autism Awareness month and there are numerous events in the US and around the world to promote this behavioral disorder. Autism Speaks provides tremendous leadership in this area and their efforts are commendable.

Wellspring too continues to do its part in raising awareness of autism in the communities that it serves. In addition to fund raising events to directly support Autism Speaks, Wellspring offices throughout Southern California participate in walks and fairs to promote this cause.

If you would like to participate or help us in this process, please let us know at info@Wellspring.com

Behavior Analysts across the nation are governed by a certification board, the Behavior Analyst Certification Board (BACB). Unlike a licensing board, certification is generally voluntary on the part of the practitioner and is overseen and directed by the profession itself. The BACB itself is overseen by an elected board of directors who are behavior analysts themselves.

Both licensure and certification specify minimal requirements for their specific credential which is generally composed of educational requirements such as degrees and coursework, and supervised practice requirements (i.e., working under someone else who is licensed and credentialed for a specific amount of time).  The BACB requires individuals to complete a specific number of coursework hours covering various areas of behavior analysis, have a degree, supervised experience hours (i.e., work in the field under a current board certified behavior analyst), and to pass a certification exam. In order to maintain certification, behavior analysts must complete continuing education credits.

The BACB came about in 1998 and has since created standards for behavior analysts including the standard exam and supervised practice requirements, an ethics or responsible conduct guidelines, disciplinary standards and procedures, as well as continuing education requirements to renew certification.

The field of behavior analysis in the state of California, like many other states nation-wide is currently moving toward licensure rather than certification (to date 6 states use a BACB credential as the basis for licensing behavior analysts). This push for licensure has been primarily triggered by autism insurance bills—bills mandating medical insurance companies to pay for ABA services for individuals with autism spectrum disorders. Behavior analysts are looking to licensure to provide them equal footing with other licensed professionals including the ability to receive reimbursement from medical insurance and other third parties. In addition to these benefits, moving to licensure rather than certification will increase the profession’s ability to protect the public from unqualified practitioners, and will force behavior analysts to develop more cohesive standards of practice and professional conduct which would then be enforced by the licensing board.

There have been 2 important bills developed in the state of California which pertain to such issues: (a) Assembly Bill 1205 (AB 1205) introduced by the California Association for Applied Behavior Analysis which outlines the requirements for one to be labeled a Board Certified Behavior Analyst and the services they can provide; and (b) Assembly Bill 171 (AB 171) which mandates medical insurance companies to pay for behavior analytic services to individuals with autism spectrum disorders.

To learn more about these issues and how they may come to affect the way behavior analysts will practice:

• Talk to your own behavior analyst who provides services to your child
• Visit the California Association for Behavior Analysts website and the Behavior Analysis Certification Board (BACB) website
• Talk to or write your local representative(s)
• Educate yourself more about the health insurance related Autism Bills and where they are at legislatively

Studies out of the University of Cambridge, particularly from Simon Baron-Cohen have indicated that one androgen, fetal testosterone, is a key factor underlying social development, and that impairments in the production of this hormone may play a role in autism.

Androgens are essentially chemical compounds in the male body that stimulate and control the development and maintenance over time of male characteristics. Testosterone is one type of androgen, and more specifically, testosterone levels in the fetus have been highly correlated with attention to detail and a number of autistic traits including empathy. The more testosterone noted in the fetus, the more likely later on the individual demonstrates deficits in “mind reading”, or inferring what a person is thinking or feeling that causes them to act certain ways. Such deficits are believed to be characteristic of individuals with autism.

Most recently Cohen’s research has confirmed earlier rodent research that shows that testosterone in early brain development organizes the activation of testosterone later in life.  In a study in which women were given testosterone they experienced reductions in their ability to mind read.  More importantly, this research showed that those who demonstrated more masculine features and thus more exposure to testosterone in the uterus showed the most pronounced reduction in the ability to mind read. In other words, those with more testosterone in uterus were shown to have more difficulty mind reading, or impairments in the production of testosterone effects later development specific to mind reading and thus empathy and to navigate social interactions. Given that people with autism have difficulties in mind reading, and that autism affects males more often than females, this study provides further support for the androgen theory of autism.

Should researchers and doctors be able identify the increased presence of testosterone in the uterus, individuals may then be identified at a significantly early age for early intervention services aimed at increasing one’s ability to mind read and related deficits, and may thus be a preventative means for autism.

Interventions aimed at increasing individual’s ability to mind read or methods of compensating for the lack of mind reading may include teaching individuals to read facial expressions, body language, and other’s tone of voice, as well as identify their own emotions, distinguishing between perception and reality, understanding that different people have different perceptions about the same thing, and utilizing social stories.

The Diagnostic and Statistical Manual (DSM) is the manual written by the American Psychiatric Association (APA) used by mental health professionals to diagnose mental illness as it details the current criteria that must be met in order for a diagnosis to be ethically given to an individual’s condition. Criteria generally outline time requirements, impact on functioning, intensity of distress, and the presence of certain mood or behaviors.

Like any other mental illnesses, to be diagnosed with autism, or Autistic Disorder, an individual must meet the criteria as outlined in the DSM. With four editions passed since 1952 when the DSM-I was released, it was not until the third edition released in 1980 (DSM-III) that “infantile autism” was included as a separate diagnostic category delineating 6 characteristics which all must have been present in order for an individual to be diagnosed with infantile autism. Prior to this, as outlined in the first and second edition, the DSM labeled those who exhibited autistic-like symptoms as having schizophrenic reaction, childhood type. In 1987 the DSM changed “infantile autism” to “autistic disorder”, and in 1994 when the DSM-IV was released, the category of pervasive developmental disorders was added including autistic disorder and 4 additional diagnoses: Asperger’s Disorder, Rett’s Disorder, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS). In the third edition the list of 6 characteristics outlined in 1980 expanded to 16 within 3 areas (social interaction, communication, restricted repetitive and stereotyped patterns of behavior) of which 6 must be present in order to be given the diagnosis  (DSM-IV TR, 2000).

The DSM is revised approximately every 10 to 15 years to reflect new research and practice, as well as changes in society including what is considered normative. As evidenced by changes in DSM criteria over the years, how autism has been understood and perceived has changed from schizophrenia as a chronic mental illness to a disorder categorized by distinct delays in development. Similarly, the new DSM-5 due out in 2013 that proposes collapsing what is now known as Autistic Disorder, Asperger’s Disorder, and PDD-NOS into Autism Spectrum Disorder (ASD) reflects 2 main points: (1) separation of ASD from typical development is reliable and valid, while separation of disorders within the spectrum is variable and inconsistent, and (2) individuals with Autistic Disorder, Asperger’s, and PDD-NOS,  are often diagnosed by severity rather than unique separate criteria defining each of these diagnoses. In other words, clinicians who utilize the DSM to diagnosis in order to guide treatment can more often agree on whether a client has a diagnosis somewhere on the spectrum, but have more difficulty agreeing on what specific diagnosis it is, and instead are more likely to use severity specifiers including mild, moderate and severe to categorize individuals on the spectrum.

As time progresses and further editions of the DSM are revised and produced, will Autism Spectrum Disorder no longer exist as a classified mental health disorder- will so many individuals fall on the spectrum that ASD will now be considered more normative and unworthy of a diagnosis?  My guess is that it is unlikely until more evidence of what causes autism is uncovered, and because ASD is a disorder of childhood linked to prevention of on-going developmental problems in individuals. Without more information about what causes autism it is anticipated that the prevalence will continue to increase as it is now teetering on being labeled an epidemic. Aside from increased early detection in order for individuals to receive early intervention, and unconfirmed recommendations regarding vaccinating young children and in general avoiding toxins, little exists in terms of large prevention efforts. Instead, focus has been on intervention, particularly for behavioral-based interventions once an individual has a confirmed diagnosis.

Many parents continue to ask “why?” when trying to understand their child’s diagnosis of autism. We have moved far from groundless accusations of “refrigerator mothers” or diagnoses of childhood schizophrenia as new studies have moved past these speculations and have linked autism to environmental and genetic factors. Since 2002, the Center for Disease Control has seen more evidence that links the symptoms of autism to environmental factors. Environmental factors refer to any living or non-living thing that effects an organism such as the land, air, water in which people or plants live. Scientists have found that even the smallest amounts of environmental toxins can have serious impact on our health. A new study conducted by Heather Volk, Ph.D. and colleagues of the Children’s Hospital Los Angeles, the Keck School of Medicine of the University of Southern California (USC) and the UC Davis MIND Institute support the claim linking autism and environmental factors. Specifically, air pollution and particle inhalation causes oxidative stress, or an imbalance in oxygen molecules in the body which reduces the ability to repair the damage of this condition.

Although researchers have speculated about its prevalence, past research has found it difficult to link environmental pollutants and autism. A recent article in TIME Magazine discussed environmental toxins such as Bisphenol A (BPA) in plastics as linked with reproductive difficulty in rats (April, 2010). The current study is the first study on environmental toxins to utilize children with autism, instead of lab animals, and uses controls from the Childhood Autism Risks from Genetics and Environment (CHARGE) study. These children ranging from 24 to 60 months at the start of the study lived in large metropolitan areas such as Los Angeles, San Francisco and Sacramento. A control group was obtained from California state birth files and matched to each child with autism by age, gender, and geographic location.

Researchers identified where the participants mothers lived throughout their pregnancy and the proximity of these homes to major roads or highways. Findings indicated that if a child was born within 1,000 feet of a highway, this was associated with a doubled increase risk for autism. This finding was controlled for by ethnicity, gender, level of education, prenatal smoking and maternal age.

It is not new that traffic-related air pollutants can be detrimental to development. In fact, a previous study from Columbia Center for Children’s Environmental Health published in August 2009 in the journal, Pediatrics found evidence of linking common air pollutants in urban areas to children’s IQ test scores. This study is just a preliminary insight into the effects of environmental toxins on increasing the risk of autism.

As parents and clinicians work to address the causes of autism by assessing individual issues each child presents with, the Autism Research Institute urges families to optimize their health prior to conceiving a child. This can include, but is not limited to, consulting with a physician regarding minimizing one’s exposure to environmental toxins and maximizing nutrition and general health of the mother prior to pregnancy. As a result of this research, practitioners are also urged to build awareness and education around the idea of risk factors surrounding autism, particularly for those who are possibly more at risk which may include families living in close proximity to freeways.