A Broad View: Disordered Eating on the Autism Spectrum
Although the average reported age for urine control was 3. Five adults, at an average age of 24, were still not toilet-trained. Behavioral issues included stuffing toilets with paper or items, continual flushing, smearing of feces, playing in toilets, and refusing to use a variety of toilets. A substantially larger sample of children and adults with autism 1, was compared with people with mental retardation 24, in terms of their motor, daily living, social, and academic skills, using a database of the New York Developmental Disabilities Information System Jacobson and Ackerman, Comparisons were made between age groupings of children 5—12 years of age , adolescents 13—21 , and adults 21—35 years.
Although the children with autism functioned at higher levels than did the children who had mental retardation without autism, these differences were no longer evident when examining the skill levels of adolescents. The advantage of children with autism was reversed in the groups of adults, with people with autism functioning at lower levels in academic and social skills although they continued to maintain an advantage in gross motor skills. Among the difficulties reported were parental problems in managing housework, due to the extra time needed to feed, toilet train, dress, engage, and put their children with autism to sleep.
Parents often felt uncertain regarding effective behavior management techniques, and most reported the use although not approval of corporal punishment. Both the children with autism and the overall family had restricted levels of contact in the community, due to either the fear or reality of increased behavioral problems during community outings. Another study compared the breastfeeding patterns of children with autism with a matched group of children with more general developmental delays, and findings were that the mothers of children with autism reported no significant differences in the offering or acceptance of breastfeeding Burd et al.
Although the range of adaptive behaviors can be defined more or less broadly, virtually all categorizations include a focus on self-care skills related to basic biological functions. In addition to issues of toileting, eating and sleep disorders are frequently reported in children with autism Richdale and Prior, However, most research on irregularities in biological functions has been based on parental report, which can be. For example, in a study of sleep patterns of 22 children with autism, aged 3 through 22, parental responses on a questionnaire were compared to direct measurement of ambulatory behavior with an actigraphic device Hering et al.
More than half of the parents reported that their children had sleep problems, including difficulty in getting to sleep, early morning awakening, and multiple night arousals. However, direct measures of non-sleep activity suggested fewer differences between the children with autism and a comparison group of normally developing children.
Children with autism, on average, tended to awaken approximately 1 hour earlier than the typical children. The investigators speculated that parents of children with autism might be more sensitive to sleep issues with their children.
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Other studies have reported rates of sleep disorders that equal or exceed those of children with other developmental disorders Dahlgren and Gillberg, , Thompson et al. Other adaptive behaviors pertain to home and community living skills, with applicable areas for young children including dressing, grooming, and safety-related behaviors. A broader perspective on adaptive behaviors may expand to school-related skills, such as academic behaviors McGee et al.
For example, children with autism often need to be directly taught how to request help when facing challenging tasks Carr and Durand, Finally, most views of adaptive behaviors also cover domains of language, social, and motor skills, which are reviewed in other sections of this report.
Not surprisingly, there are correlations between levels of adaptive skills and intellectual ability Carter et al. For example, lower cognitive and verbal levels are highly correlated with age of accomplishment of bowel and urine training Dalrymple and Ruble, However, successful use of toileting intervention procedures based on operant and classical conditioning may be more related to physical maturity and social responsiveness than to cognitive level Azrin and Foxx, There is some evidence that levels of adaptive behavior predict future independent functioning more accurately than measures of cognitive or academic functioning Carter et al.
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Such measures provide clinicians with an estimate of the degree to which the child can meet the demands of daily life and respond. A significant discrepancy between IQ and the level of adaptive skills or between observed performance in a highly structured situation and in more typical situations indicates that an explicit focus on acquisition and generalization of adaptive skills is important. For a diagnosis of mental retardation, assessment of adaptive level is required. Assessment of adaptive functioning is particularly important for children with autism for several reasons.
As with other children with developmental difficulties, acquisition of basic capacities for communication, socialization, and daily living skills are important determinants of outcome. Significant discrepancies, for example, between performance in a highly structured setting and in less structured settings, or between intellectual skills and adaptive abilities, indicate the importance of including an explicit focus on teaching such skills and encouraging their generalization across settings.
Second, assessment of adaptive behaviors can be used to target areas for skills acquisition. Third, there is some suggestion that relatively typical patterns of performance in autistic spectrum disorders can be identified and that some aspects of adaptive assessment e. This can be especially important in high-functioning children, in whom IQ scores may not reflect the ability to function independently in natural environments.
Fourth, assessment of adaptive skills, as well as of intellectual ability, is essential in documenting the prevalence of associated mental retardation and, thus, eligibility for some services Sparrow, The Vineland assesses capacities for self-sufficiency in various domains such as communication receptive, expressive and written language , daily living skills personal, domestic and community skills , socialization interpersonal relationships, play and leisure time and coping skills , and motor skills gross and fine.
A semistructured interview is administered to a parent or other primary caregiver; the Vineland is available in four editions: a survey form to be used primarily as a diagnostic and classification tool for normal to low-functioning children or adults, an expanded form for use in the development of indi-. Particularly for children with autistic spectrum disorders, the expanded or preschool form may be most helpful since it can be used to derive goals that can be directly translated in an individualized education plan IEP Volkmar et al.
In addition, several research studies have delineated Vineland profiles that are relatively specific to autism Loveland and Kelley, ; Volkmar et al. This unique pattern consists of relative strengths in the areas of daily living and motor skills and significant deficits in the areas of socialization and, to a lesser extent, communication. Supplementary Vineland norms for autistic individuals are also now available Carter et al.
A primary consideration in selection of adaptive living goals should be the skills needed to promote age-appropriate independence in community living, so that a child can have access to the larger social community. For example, children who are not toilet trained are not likely to have access to classrooms with normally developing peers, and parents of children who present safety risks will be less likely to take them on community outings.
Thus, parents and teachers are pleased when their child makes tangible early progress, and they may be motivated to collaborate on more challenging tasks. There are a number of published manuals that provide practical guidance on the design of instructional programs, along with detailed task analyses of various daily living and self-help skills. For example, Steps to Independence Baker and Brightman, provides easy-to-follow guidelines for teaching skills such as shoe tying or hand washing. Behavioral intervention techniques can readily be used to teach adaptive skills e.
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Additional resources for commonly encountered difficulties include books written for parents on eating disorders Kedesdy and Budd, and sleep problems Durand, The books listed above, and similar resources, include suggestions for data collection during baseline planning, implementation and follow-up. The complexity of the data collection procedure will vary according to the challenge of the skills being taught e.
Ongoing assessment typically requires at least some baseline measurement, as well as periodic measures of skill performance during and after intervention. In order to assess the level of independence achieved for a given skill, it is necessary to evaluate the performance of the new skill in conditions of decreasing prompting. With the exception of research in communication and socialization, there are surprisingly few studies that directly evaluate the use of behavioral interventions to teach adaptive skills to young children with autism. However, there is a body of research on reinforcer potency that is directly relevant to efforts to use behavioral techniques for skill instruction with children with autism.
Thus, constant versus varied reinforcement procedures were compared in a study of the learning patterns of three boys with autism, aged 6 to 8 years Egel, Using a reversal design, it was shown that correct responding and on-task behavior during a receptive picture identification task increased using varied reinforcers. Satiation for food reinforcers was problematic in conditions in which constant reinforcers were used. Thus, a grooming checklist e. Applications to young children with autism would likely involve both skill building and assistance to parents in managing the responsibilities of caring for their children with autism.
Appearance becomes a practical concern as more and more children with autism are gaining access to inclusion with typical peers, and attractiveness may influence their receipt of social bids. Thus, a variety of approaches have been used to increase engagement both with adult-directed tasks and in general attending to the environment; these include delayed contingency management Dunlap et al. Inclusion and interaction with typically developing peers Kohler et al.
Now that children with autism are beginning to gain access to regular preschool and elementary school settings, there has developed a need for teaching them to transition smoothly across educational activities Venn et al. As discussed earlier, there have been demonstrations that young children with autism can be taught to increase the frequency and variety of their play skills.
Such interventions are expedited by pivotal response training and by targeting the skills displayed by typical children at similar developmental levels Lifter et al. Young children with autism have been taught peer imitation abilities in the course of Follow the Leader games Carr and Darcy, Virtually all of the well-known programs for young children with autism provide instruction in adaptive daily living skills, which often form the basis for development of communication, social, and even motor skills.
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Several published program outcome evaluations have specifically examined progress in adaptive skills as measured on the Vineland. For example, 20 children with autism enrolled in the Douglass Developmental Disabilities Center showed better-than-average progress in all four domains assessed on the Vineland, but the most marked progress was in communication skills Harris et al. Similarly, the Walden family program component was shown to yield developmental gains that were larger than those expected in typical development i.
The nine children with best outcomes in the treatment outcome study Lovaas, were reassessed at an average age of Although their overall composite scores were within the normal range, five of the nine had marginal or clinically significant scores in one more domain. Results were. A more recent systematic replication compared intensive and nonintensive interventions Smith et al. A randomly assigned group of children with autism and pervasive developmental disorder-not otherwise specified PDD-NOS received intervention for approximately 25 hours per week for at least 1 year, while a similar group of children received 5 hours per week of parent training over a period of 3 to 9 months.
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Vineland results showed no significant differences between the two intervention groups. Unless a specific focus on generalization of skills is included in the intervention program, it is possible for children with autistic spectrum disorders to learn skills in a highly context-dependent way. That is, even though a child is capable of some particular behavior, it occurs only in highly familiar and structured contexts. Thus, results of adaptive behavior assessments have been less robust in some cases McEachin et al. However, inclusion of an explicit home-based program has been reported to be associated with progress on measures of adaptive behavior Anderson et al.
Because there is a substantial literature about teaching adaptive skills to children with developmental disabilities, one question is how often and when strategies that are effective with other populations of young children are applicable to children with autism. Skills requiring specific adaptations peculiar to autism may benefit from direct investigation e.
A major adaptation that is often required is the improved assessment and selection of reinforcers so that the child with autism will be motivated to develop new adaptive skills Mason et al. Questions of generalization are important but need to be considered for a particular behavior and child. For example, a child might learn a very structured tooth brushing routine that is tied to a specific kind of toothbrush—which may be very helpful even if not very generalizable.
However, only using a particular kind of toilet would be much more problematic. Overall, results are encouraging regarding the potential for teaching a range of adaptive behaviors to young children with autism.
There is substantial data, particularly with older children and adolescents, that behavioral interventions, particularly those with attention to generalization, can result in improved adaptive behavior in children with autism. Adaptive goals are a significant part of both home and school programs for young children. Although general measures of adaptive behavior may indicate increasing discrepancies from normal development with age, the potential to make practical changes in the lives of children with autistic spectrum disorders through teaching specific skills that have value in the community e.
Teaching adaptive skills, with specific plans for generalization across settings, is an important educational objective for every young child with autism. At this time, the greatest challenge is one of translation from research to practice.