Autism has been around forever, yet we are still learning so much about it every day.
As we take a look at a situation involving a girl named Marissa, we see how the affects of autism affect many people.
Marissa is an adolescent who was adopted at 26 months by a single parent Catherine from a Russian orphanage. Despite a nurturing and empathetic mother, Marissa has some self-injuring behaviors such as hitting herself and saying negative comments about herself. She hits herself when she feels afraid or thinks that her mother is upset with her.
Catherine has become involved with another woman. They recently adopted another child, a young boy. They also moved to another state due to Catherine’s partner’s new job. Marissa, recently diagnosed with Asperger’s (AS), has digressed in behavior by screaming at the baby when he cries. Before the move, Marissa was getting along with the baby. In the past, Marissa was doing okay in school despite her over-all learning challenges. Now, with the move, she has begun to have problems adjusting. She was placed in a self-contained classroom.
Some of the presenting symptoms Marissa has that could be because of the Asperger’s diagnoses are the negative self-talk and the self-injuring. Marissa also is very good in music and enjoys piano. Many children on the autistic spectrum have a special area of interest that they tend to do well with. Many AS children also have learning issues, such as Marissa. Marissa also does not make friends easy. This lack of social ability is one of the hallmarks of the autistic spectrum disorder.
Fifty years ago, the diagnosis of Asperger’s or other autistic spectrum disorders ranged only 1 in 10,000. In the past twenty years, and even more recent, there has been an increase in diagnoses of Asperger’s to the rate of 1 in 50 to 1 in 150 (Mercola, 2011). What is causing this increase? Some doctors say it is because of better diagnosing instruments. Others say it is the increase of toxins in the environment that is causing the increasing numbers. Others say we are just more aware of the habits; giving them a diagnostic name rather than just calling the individual ‘eccentric.’
To earn a diagnosis of Asperger’s, an individual must exhibit delays in the areas of at least one of the areas of communication, socialization, or restricted behavior before the age of 3 (NIMH, 2009). Some of the early symptoms for diagnosis are:
- Does not babble, point, or make meaningful gestures by 1 year old
- Does not speak before age 16 months
- Does not combine words by 2 yrs
- Does not respond to name
- May lose language and social skills (this can occur in a normally developing child after receiving immunizations)
- Poor eye contact
- Does not understand how to play with toys in a normal fashion
- May be obsessive about lining up toys or other objects
- May be obsessively attached to one object
- Does not smile or interact happily
- At times appears not to hear normally
- For some, may have language but tends to ‘echo’ what he hears from videos or other conversations
- May have important delays in fine and gross motor skill development (Rudy, 2011)
Autism spectrum disorder is actually a range of symptoms. Some children are extremely affected so they cannot communicate at all or even learn to be potty trained. Others are at the end of the spectrum that they only appear a little ‘off’ from a normal child. They may be on the outside of the social circle where they can play happily by themselves. Children on this side will be labeled with Asperger’s or high functioning autism.
Symptomology of issue, give specific samples
As Marissa spent her first two years in an orphanage, she was unable to form attachments to any significant caregiver. Additionally, she shows a delay across all areas. This is common in children with AS. Marissa has a strong interest in music and piano playing. It is very common for children with AS to have a strong interest in one area.
Marissa was improving in her interactions with her family until they moved. The change caused her to relapse into some negative behaviors. Change often does this to children with AS. They need a very structured life. When moving, it is often suggested by parents with autistic children to take them to the new home a couple of times to show them where they will be living. With Catherine moving her family across the country, they were unable to do a pre-move trip.
How it is affecting child:
Since the move, Marissa has been acting out to the new baby. She screams when the baby cries. Many children with AS also have sensory processing disorders (SPD)(Sicile-Kira, 2010). They tend to be very sensitive to sound. SPD often causes more problems than other characteristics to children and adults with autism spectrum disorder (ASP). This SPD could also be the cause Marissa has regressed in her school activities. There are many changes in her life. AS children do not accept changes very well. Marissa now has to be placed in a self-contained classroom.
As Marissa’s parents are feeling the stress of being in a very conservative neighborhood with their mood, Marissa is probably picking up signs of this. This can add to her stress to the change in environments. Marissa is also now surrounded by an extended family which adds more people into the mix.
Marissa is at the age of starting puberty. This is a very chaotic time for many children, especially those with autistic tendencies. In interviewing many families with children on the spectrum, it is a common occurrence that children become more symptomatic during puberty. This is especially true of the first year. After 12-18 months, the youth tends to calm down back to the level of symptoms before puberty changes.
Depending on the intervention measures, some youth with this disorder will become less symptomatic as they move into their mid to older teen years. Some characteristics tend to remain, although they are not as prevalent. Some of these intervention measures may include dietary and supplement measures (Bock & Staut, 2007). Other teens will become adults who are considered ‘eccentric.’ This depends on the level and type of interventions used in childhood. The earlier the intervention, the more likely the child will develop according to normal developmental guidelines.
Legal or ethical considerations:
When working with children, ethics issues such as confidentiality are very important. Because they are children, the parents have the right to know what is going on in the sessions. On the other hand, children need a safe place to be. The child and parent need to be informed of the special circumstances when the counselor will have to tell third parties in the case of abuse or neglect. The counselor also will tell someone else if the client talks about hurting themselves or others.
It is also ethically important that the counselor be competent in working with children. They are not small adults. They have special issues that counselors need to be knowledgeable about such as development and communication abilities.
The counselor also needs to be knowledgeable about the client’s ethnic background and their cultural traditions. In this case, with a homosexual mother, the client needs to be accepting and non-judgmental about the sexual orientation of the parent. The parent orientation does have some bearing on the child and her perception of the world.
When dealing with special needs children, ethics are even more important. With a case such as Asperger’s, it is important that the counselor is very knowledgeable about this range of this disorder. It is important she knows the various available programs such as Relationship Development Intervention (RDI) to work with autistic children. Another program that could be very helpful with a play therapist would be Floortime (dir floortime, n.d.). This play therapy program was developed specifically to work with the autism disorders. Competency is essential when working with children, especially those with special need issues.
Literature review on autism and its intervention:
With the epidemic number of autism that has grown over the past two decades, there has also been an increase in research. From the early years, mothers were called ‘refrigerator’ mothers (Peregrin, 2007) who did not show enough affection to their child who caused the ensuing problems. A well-known case is Temple Grandin (Grandin, 2010). The doctors accused Temple’s mother of being cold and uncaring. Temple’s mother was just the opposite. She did everything she could to reach her child. Because of her efforts, Temple has reached world-wide fame today.
As time passed, research has shown that autism has a genetic family link (Lathe, 2006). With genetic studies, the incidence of family linkage is high. Among twins, there is a 90% co-occurrence (Szatmari, et al, 2007). Within the family, there is an aggregation for many autistic traits including unusual sensory interests, compulsions, resistance to change, obsessiveness, and nonverbal IQ scores (Szatmari, et al, 2007). Piven (1999) reported that this aggregation of autistic traits among non-autistic family members creates a “broad autism phenotype” (Piven, 1999, p. 299). Research into this phenotype can help determine the familial genetic influence on the causes of autism.
One of the most common beliefs among parents for the causes of autism is the “leaky gut” syndrome (Lewis, 1998). Urinary peptide counts were discovered among autistic children 20 years ago (Knivsberg, et al, 2003). Autistic children are often bothered by gastrointestinal problems. They suffer from constipation, diarrhea, bloated abdomen, cramps, and flatulence (Erikson, et al, 2005). As mentioned earlier, there are many studies researching the cause by the incomplete peptide chains breakdown in these children. Certain foods containing gluten and casein appear to cause worsening of symptoms.
Another popular belief as to the cause of autism is environmental causes. There are still people who believe that mercury in immunizations are responsible for their child’s symptoms, especially the MMR shot (Bock & Staut, 2007). Many children do not show any symptoms of autism until their immunizations (Gardner, 2008). Doctors insist that immunizations are not the cause of autism. Szpir (2006) reports that genetic inheritance puts these children at a vulnerability to the toxins in uterus, along with environmental impacts. With the addition of the immunizations, it just pushes the system to overload and symptoms erupt (Szpir, 2006). Lathe (2006) said that tests show autistic children demonstrate toxic levels of heavy metals. The tendency to toxic levels could also be inherited (Lathe, 2006). Lathe (2006) reports that liver and kidney functions are dysfunctional in autistic children. This follows that toxicity would exist as these organs filter the blood.
Seitler (2010) discussed in his research article that autism was almost unheard of until the 1930s when the immunization program began the use of mercury. With the increase in the number of diagnoses and the increasing number of immunizations children are hit with at an early age, this concept has some importance to consider. Seitler (2010) also adds that our bodies are hit with an increasing number of chemicals in our food supply. This increases the toxic hit our children suffer. As Szpir (2006) states, the number of toxic hits tend to bring on more autistic symptoms.
In other topics of literature is the intervention with ASD. As with most disorders, the earlier the intervention the better (Tews, 2007). Many children with ASD the symptoms are recognized in the primary grades and intervention are started. With Marissa, as with many with Asperger’s, diagnosis did not come until her adolescent years. Because of this, treatment might be hampered. It may take longer to find the right combination of options to help Marissa achieve her fullest potential. Things like changing the diet for food sensitivities might also be harder at older ages.
Some of the types of intervention discussed by literature include using video to teach reciprocal play skills (MacDonald, Sacramone, Mansfield, Wiltz, & Ahearn, 2009) using music (Whipple, 2004), and dietary and CAM interventions (discussed elsewhere).
Video has been proven effective in teaching children play skills. After the use of video, the children would play with other children appropriately and use language during play. Music showed improvement in social behaviors and decrease in self-stimming; increased attention to current task; increased verbal language; increased engagement; increased body awareness; improvement in self-care activities; and lessening of anxiety (Whipple, 2004). Since Marissa enjoys music, this type of treatment could be utilizing during play therapy to help.
Other popular literature study the subject of food issues which many children with ASD have. Many children will be ‘finicky’ eaters where they will eat only certain types of food. Since autism children tend to have sensory processing issues. Because of these, they may only eat crunchy things or soft things, etc. Wood, Wolery, & Kaiser (2009) created a case study on how to help young children in expanding food selectivity. They did this through the use of video and co-eating between therapist and child with child-size tables/food.
Concerning another food issue in literature is about a case control study by Mehi-Madrona, Leung, Kennedy, Paul, & Kaplan (2010) discuss the treatment comparisons between children whose parents used CAM treatment with diets and supplements to clients whose parents used only traditional medicines. Those who followed CAM methods made more significant improvement. With the medical intervention, there was no lessening of symptoms.
There are a number of research articles dealing with utilizing a gluten-free/dairy-free diet and/or supplements. Dietary methods appear to be one of the most effective to help control symptoms over all. At the present time, there needs to be more studies with double-blind cases such as Elder, Shankar, Shuster, Theriaque, Burns, & Sherrill’s study (2006). In this study, parents found an improvement in their child’s behavior within the 12 weeks of the study. There were limitations to the study due to the size of the test group. The major problem in creating such studies is that there is a wide variety of symptoms in children with ASD.
Neuroscience and Autism:
With the variety of symptoms of autism, some scientists have looked into some of the causes of the over/under-reactivity to sensory stimuli, along with self-stimming behaviors. With these issues and the core symptoms dealing with communication and social skills led many to believe that autism is a disorder of the sensory modulation (Jou, Minshew, Melhem, Keshavan, & Hardan, 2009). Jou, et al. (2009) found that the pathology was found throughout the brain in autism clients.
In research for autism, some scientists have looked into the volume of the amygdala and the hippocampus. The amygdala is important for the processing of emotion such as fear (Williams, 2008). The hippocampus is for learning and memory. All of these processes are affected in persons with autism. In some cases, there have been clients who have smaller structures, others have larger. At the present time, it is decided that autism affects the size of these structures, but the structures’ sizes do not cause autism.
Another physical brain difference found in children with autism is that the head circumference in almost all young children with ASD is too large in comparison to height. When considering the gray and white matter of the autistic brain, the gray matter appears to be increased in the frontal, occipital, and temporal lobes (Williams, 2008). White matter is increased in all regions of the brain, especially the frontal lobe. The gray matter is the neurons, whereas the axons connections are covered with myelin sheaths and create the white matter.
Other differences deal with the reduced synchronization between important brain regions for various cognitive tasks. Processing connections tend to be too strong. Understanding how these differences exist in the client with autism spectrum disorder can help the therapist decide on more effective treatment options (Williams, 2008).
For counseling intervention, some therapists use Pivotal Response Training, Discrete Trial Instruction, and Picture Exchange Communication Systems for the characteristic of generalization (Schutte, 2010). This is called Applied Behavior Analysis (Schutte, 2010). Cognitive behavior therapy is also used for some actions (Bock & Stout, 2007). One treatment that is very popular is Relationship Development Intervention (RDI) (Rudy, 2008). Dr. Steven Gutstein developed this intervention method to help correct the core of missing pathways in the brain (Rudy, 2008).
Other treatments used include occupational therapy to teach skills like dressing and bathing, and physical therapy to teach skills concerned with body movements. Play therapy, sensory integration therapy, story therapy, and communication therapy are also included in some children’s treatment depending on level of effectiveness (MedLine, 2010). For the psychotropic side, there is no “cure” for autism by medication. Some children will take medication for depression and anxiety if needed (MedLine, 2010).
Many parents use complementary and alternative medicine (CAM) techniques to treat their children (Wallace, 2009). Supplements may be used with or without doctor knowledge or guidance. The most common supplements are vitamins B, fish oil, and magnesium (Sicile-Kira, 2006). Because of the “leaky gut” and malabsorption tendencies of the autistic child, supplementation helps with finicky eaters.
Parents from all over the world have put their children on various diets and supplements. The most popular diet is the gluten-free/casein-free diet (gf/cf) (Lewis, 1998). Bock & Stout (2007) treat hundreds of children with a combination of the gf/cf diet and supplements at times. They see significant improvement in over 85% of cases (Bock & Stout, 2007). Bock has a regimen that he puts his patients on. The gf/cf diet is the first step. Over 50% improve within three months (Bock & Stout, 2007). If this does not work, then he continues with supplementation and eliminating other possible allergens until improvement happens.
Play therapy application:
Working with Marissa, this therapist would begin by examining her daily habits, including diet. Research has shown that diet affects behavior and the strength of symptoms of autistic children. We would begin by perhaps doing an elimination diet to see how re-introducing certain foods would affect Marissa. A very important part of this would be working with Catherine to keep track of foods and reactions. The diet would have to be adhered to. To help in the beginning, foods that are the most common sensitivities could be used. The most common ones are yeast, gluten, and corn (Bonnie, 2010). Bock & Staut (2007) created a very effective dietary method that helps 75% of children significantly. The other clients improve in small increments. As they find more food sensitivities, improvements appear.
The next step would include perhaps some group activities to see how Marissa interacts with other children. This therapist might take some time to observe her in her school situation, if possible. Tekin-Iftar & Birkan (2010) researched how children with ASD improved with group learning skills. By observing each other learning skills, the children improved in needed areas. With Marissa, this information could be used to help her learn social skills with other youth who may have ASD issues. In some communities, the local Autism Societies create youth groups, especially for teens, who can meet monthly to learn social skills and to practice them. In this writer’s own community, the teens with Asperger’s meet in such situations. They watch movies, go bowling, or go skating. In this way the youth learn to interact in society easier.
Other group activities that have been effective with this parent’s own life have been such organizations such as 4-H and Scouts. This allows the youth to find areas they can develop their own interests while learning positive characteristics. It gives them positive social situations in which they are associating with other children with like interests. In some communities, they do have special scout groups created especially for children with Asperger’s. In such organizations such as 4-H, they make special considerations for children with challenges. If Catherine was able to put Marissa in such a group, it would allow her to meet other children in the new neighborhood, along with learning needed social skills. Marissa would also be able to work on things within her interest level of music and piano.
There are some programs that are very effective in teaching children social skills, such as RDI (Rudy, 2008). This program is one that parents can work with their children at home. It is a behavior modification program (Autism Speaks, 2011). It is to help children improve their social skills, self-awareness, and flexibility. Working with Marissa, such games would teach skills such as reading body language and facial expressions. Feeling chart pictures would be a useful tool working with autistic children. This would provide them an easy way to practice reading expressions which is a common problem. There are also games that talk about feelings. Autistic children often have problems labeling their feelings or even being aware of others’ feelings. They do not normally understand things like empathy. Playing with the child a game that may present various situations, then the therapist could ask the child how they think the presented person would feel. This could later be generalized to children at school, siblings, or parents.
Because play therapy is very important even with adolescents, this worker would probably work on a rotating basis with allowing Marissa to choose free play one time and then have a more directed play with games. She would be able to choose between certain games that were laid out for her visit. Other weeks, she may have the choice to choose between story books to be read where we could discuss things like friends, reading expressions, how would you feel, etc.
Three quarters ago when I chose this client, I had no idea she would be diagnosed with Asperger’s. She pulled on me as a client because of her self-injuring behavior and her negative remarks about herself. During a large part of my younger life, I was a self-injurer from about the age of five. It took a long time for me to learn about the basis of this self-injuring and to break the addictive habit.
There were also a number of years where I was very negative about myself. I did not have anything good to say about myself. It took several years in counseling as an adult to change my self-esteem where I could learn to love myself.
Another point about Marissa was the abandonment issues she faced being raised in an orphanage her first couple of years. As a young adolescent, I was also abandoned by my parents. I was taken to my paternal grandparents to live for my junior and senior high school years.
With these three points, I can understand how I was drawn to work with Marissa as a client as I knew I could connect with her. I knew where she was coming from. This quarter I learned she was diagnosed on the autism spectrum disorder scale. This is one field I have spent the last five years researching everything I can get my hands on. Asperger’s is something that is in my own family. It is something I have spent hours researching in order to best help my youngest son to achieve his highest potential.
If Marissa were a real client, I know that I could help her and her family. From the first when she pulled at me, I knew that my life experiences and education would be a perfect fit to reach this troubled young girl.
At times in the past I would wonder why God had allowed so many negative things to happen to me and my family. Now, I look at these events and challenges as simply God providing me more tools where I can reach out to help others. There is a saying that says, ‘What doesn’t break you makes you stronger.’ I know that I have become a very strong person because of the experiences of my life. As such, I will be able to have life experiences that will give me connections with a wide variety of clients, such as Marissa. As a parent with a child with Asperger’s, I can connect with parents such as Catherine to share ideas about how to best help her child. I know the emotions and frustrations she may be feeling. I know of her desire to give her child the best life she can, as evidenced by her changes to accommodate Marissa’s challenges.
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