Κριτικές του άρθρου
Theories – Assessment from the view of Speech and Language Clinical Practice for children/ young people with ASD
Θεωρίες – Λογοθεραπευτική Αξιολόγηση παιδιών/ νέων ατόμων με Διαταραχές Αυτιστικού Φάσματος
Anastasios M. Georgiou
Αναστάσιος Μεν. Γεωργίου
Autism is the result of a neurological disorder that has an effect on normal brain function, affecting development of the person's communication and social interaction skills. The aim of SLT assessment is to gather and record information that enables diagnosis. Such an assessment is necessarily comprehensive and might take place over a period of time. The process of assessment aims to review functioning in relevant domains and facilitate intervention. Specialist assessment in general should include a history-taking element, a clinical observation assessment element, and the obtaining of wider functional information. Almost anyone diagnosed with an autism spectrum disorder will be recommended for speech therapy. Speech therapy involves much more than simply teaching a child to correctly pronounce words. In fact, speech therapists who deal with autism, work on diverse linguistic areas in which people with autism have difficulties regarding acquisition and generalization.
Ο Αυτισμός είναι το αποτέλεσμα μιας νευρολογικής διαταραχής που έχει επίδραση στη φυσιολογική λειτουργία του εγκεφάλου, επηρεάζοντας την επικοινωνία και τις δεξιότητες κοινωνικής αλληλεπίδρασης του ατόμου με αυτισμό. Ο στόχος της λογοθεραπευτικής αξιολόγησης είναι η συγκέντρωση και καταγραφή πληροφοριών που προάγουν τη διάγνωση. Μια τέτοια αξιολόγηση είναι απαραιτήτως εξονυχιστική και μπορεί να είναι και χρονοβόρα. Η διαδικασία αξιολόγησης έχει ως στόχο την εξέταση της λειτουργικότητας του ατόμου και τη διευκόλυνση της παρέμβασης. Γενικότερα, οι αξιολογήσεις των ειδικών πρέπει να περιλαμβάνουν τη λήψη ιστορικού, την κλινική παρατήρηση, καθώς και την εξασφάλιση ευρύτερων πληροφοριών. Σχεδόν οποιοσδήποτε διαγιγνώσκεται με διαταραχή φάσματος του αυτισμού παραπέμπεται για λογοθεραπεία. Η λογοθεραπεία περιλαμβάνει πολύ περισσότερα από την απλή διδαχή της ορθής προφοράς των λέξεων. Στην πραγματικότητα, ο λογοθεραπευτής που ασχολείται με αυτισμό ασχολείται με ποικίλους τομείς της γλώσσας, στους οποίους τα άτομα με αυτισμό παρουσιάζουν δυσκολίες ως προς την κατάκτηση και τη γενίκευσή τους.
Autism stems from the Greek word "autos" which means "self." The term was firstly introduced by a Swiss psychiatrist named Eugene Blueler in 1912. He used the term in order to describe schizophrenic patients who were in catatonic states. Bleuler referred to solitariness and withdrawal that those people exhibited.
The classification of autism did not occur until the middle of the
twentieth century, when in 1943 psychiatrist Dr. Leo Kanner of the
An Austrian scientist named Hans Asperger described children in his practice who lacked nonverbal communication skills, demonstrated limited empathy with their peers, and were physically clumsy. The majority of his work wasn't widely read until 1997 and was not translated in English for almost 50 years. Gena  argues that autistic disorder or Autism comprises a type of Pervasive Developmental Disorder and has been defined as a “spectrum” disorder, with the term “spectrum” indicating the variation in the clinical phenotype observed. Firth  notes that autism influences the whole mental development and under no circumstances should it be perceived as a static situation since as time passes, the same person exhibits different autistic traits.
According to DSM-IV (1994)  the prevalence of autism is estimated to be approximately 2-5:10000 children, 3-5 boys: 1 girl. However, according to the Center for Disease Control and Prevention (1997) prevalence is estimated to be approximately 1:10000 children.
Etiology of autism
Autism breeds “decrease” in: reciprocal social interaction, verbal – nonverbal communication, general behavior, interests, activities. In the above domains, people with autism do not always differ because of a delay in the process of development, but they exhibit deviant behavioral patterns which are not observed in typically developed individuals . Fundamental impairments of social communication tend to persist throughout life! Although autism influences the whole mental development, under no circumstances should it be perceived as a static situation since as time passes, the same person exhibits different autistic traits .
Before 1970 (i.e. Αsperger, 1944; Bettelheim, 1967; Κanner, 1943) scientists believed that autism was a consequential condition of parental neglectfulness (environmental- psycho-genetic explanation of autism). However, more recent studies demonstrated the insufficiency of such theories, since they provided potent arguments of genetic contribution to this condition (e.g. Baron-Cohen, 1995; Brothers, 1999; Gilberg, 1983; Ritvo et al., 1985 Szatmari & Jones, 1991). Nevertheless, autism is a complex neurodevelopmental disorder and as Gena  argues, it is unknown whether autism is a unique entity regarding its aetiology, or else comprises the expression of multiple complex causes.
Theory of Mind (ToM) (Baron-Cohen 1995; Baron-Cohen, Leslie, & Frith 1985)
Having a theory of mind is to be able to reflect on the contents of one’s own and other’s minds . When we mind-read or mentalize, we not only make sense of another person’s behavior (Why did their head swivel on their neck? Why did their eyes move left?), but we also imagine a whole set of mental states (they have seen something of interest, they know something or want something), and we can predict what they might do next .
In a great deal of studies (e.g. Baron-Cohen, Leslie & Frith, 1985; Baron-Cohen, Leslie & Frith, 1986; Leekam & Perner, 1991; Perner, Frith, Leslie & Leekam, 1989; Reed & Peterson, 1990; Swettenham, 1996; Swettenham, Baron-Cohen, Gomez & Walsh, 1996)  it is argued that children with autism have difficulties in shifting their perspective to judge what someone else might think. What do they do instead? They just report what they themselves know.
The theory of mind model has its limitations in explaining autism .
Children with Asperger's syndrome are not more competent in theory of mind
tasks than children with autism within the normal range of intelligence.
Therefore, we need to review whether the classification of autism on the basis
of symptoms exists. Besides, we expect the publication of DSM-
The Empathizing-Systemizing Theory (Baron-Cohen, 2002)
Two parameters are taken into account: empathy (below average) and systemizing which is a psychological factor (either average or even above average). Systemizing is the drive to analyze or construct systems (any kind, e.g. abstract, natural and technical). In other words when we systemize we have knowledge of the rules which govern the system, in order to predict how that system will behave (Baron-Cohen, 2006). When we systemize we know the rules and regularities (structure) of a system.
Prows of the E-C theory 
This is a two factor theory. In other words it explains both social and nonsocial traits in autistic spectrum conditions. Below average empathy is a simple way to explain the social and communication difficulties, whilst average or above average systemizing explains the narrow interests, repetitive behavior, and resistance to change/need for sameness. Furthermore, it does not focus only on the areas of difficulty (empathy) but also on the areas of strength (systemizing) in ASCà ASD is viewed as a difference in cognitive rather than as a disease.
Poor executive functioning 
Executive function comprises planning working memory, impulse control, monitoring of action etc. All are thought to depend on systems that involve prefrontal activity in the brain in normal individuals. In autism poor performance is observed in many tests related to executive function (e.g. Rumsey & Hamburger 1988; Szatmari et al. 1989; Prior & Hoffmann 1990; Ozonoff et al. 1991; Ozonoff & McEvoy 1994; Ozonoff 1995; Bennetto et al. 1996).
Weak central coherence (Happe, 1995)
Central coherence is the ability to see the “big picture” rather the details. Central coherence theory explains the non-social features of autism. According to the theory, people with autism tend to focus on details, rather than the global aspects of an entity. However, Hill and Frith  argue that the main problem of the central coherence theory of autism, and its variants, is a lack of plausible neuroanatomical mechanisms in which the nature of the abnormal activation could illuminate the observed behavioural features. Clearly, a great deal of neuroanatomical work must be done to investigate this.
Deficiencies , 
Deficiencies are observed in attention, spoken language, social and emotional expression, play, sensory process and cognitive skills. However, scientists also refer to some special skills, such as exceptional ability of memorization, high ability in maths, hyperlexia and skillfulness in puzzles and complicated games, which people with autism have.
¨ eye-to-eye gaze
¨ persistent preoccupation with part of objects
- Spoken Language
¨ disturbed articulation
¨ speech and language absence or delays
¨ inappropriate laughing and giggling
¨ repeated speech
An aspect of language that tends to be disturbed in autistic people has to do with knowing how to use language appropriately and in context. That includes knowing how to hold a conversation, thinking about what the other person in a conversation understands and believes, and tuning in to the meta - linguistic signals of the other person, such as facial expression, tone of voice and body language
- Social and Emotional Expression
¨ avoidance of physical contact (e.g. no seeking of cuddling)
¨ avoidance of social interaction
¨ indifference towards peers
¨ indifference towards humans in general
¨ lack of empathy
Phil Schwarz, a software developer from
The "intense world"
theory , which has been put forth by Henry and Kamila Markram of the Swiss
Federal Institute of Technology in
¨ peculiar/ odd play
¨ absence of symbolic play
¨ absence of interactive play
¨ excessive preoccupation with certain games
- Sensory Process
¨ peculiar processing of visual stimuli (e.g. fixed stare)
¨ indifference or excessive response to auditory stimuli (e.g. they do not respond to excessive noise, but they close their ears with the sound of an electric brush
¨ indifference or excessive response to tactile stimuli (e.g. they do not respond to painful stimuli, but they cannot stand tender caresses, etc..
- Cognitive Skills
¨ inconsistent learning
¨ stereotypes (in visual stimuli, smell, speech, taste, move, routines or rituals)
Autism might coexist with many other conditions. For example, 30% of people with autism develop clinically apparent seizures (imbalances in cortical circuits) (Lord and Spence, 2006). Furthermore, autism may coexist with neurofibromatosis, congenital rubella, hydrocephalus, ambulation, fetal alcohol syndrome and fragile X syndrome. It is estimated that at least 24% of cases of autism are potentially associated with other syndromes, to infective, metabolic or genetic pathologies, and to anatomical or functional alterations . Studies to date report that somewhere between 2% (Collacott et al. 1992, cited in Hepburn, 2007), 5% (Ghaziuddin et al. 1992, cited in Hepburn, 2007), 7% (Kent et al. 1999, cited in Hepburn, 2007) and 10% (Paly & Hurley 2002, cited in Hepburn, 2007) of individuals with Down syndrome meet the criteria for autism or autism spectrum disorders . Although there is a substantial amount of research to support high rates of ID (intellectual disability) in autism (70-80%), this finding has been disputed in an extensive review by Edelson .
Currently, eating and feeding disorders have been associated with ASD. Pica is defined as the persistent eating of nonnutritive substances for longer than one month that is inappropriate for one’s developmental level (APA, 2000). Lo Vullo  argues that the rates of Pica may be higher in ASD than in other developmental disabilities. The identification and treatment of Pica is crucial because this behavior can lead to severe medical complications, including intestinal parasites, infections, surgical complications from removing objects, toxicity, and death . Rumination Disorder is defined as the repeated regurgitation and rechewing of food, with a pattern that occurs for longer than one month that is not attributable to a general medical condition, anorexia, or bulimia (APA, 2000). The comorbidity of rumination and ASD has not been supported. However, 6-10% of institutionalized individuals who have severe or profound ID ruminate on a regular basis (Fredericks, Carr, & Williams, 1998).
Assessment from the view of Speech and Language Clinical Practice – Diagnostic criteria
However genetic contribution to autism has been supported, the diagnosis of this condition looks to behavioral characteristics. According to ICD-10 – DSM-IV  the symptom criteria for diagnosing ASD, are based on a triad of impairments:
Social: impaired, deviant and delayed or atypical social development, especially interpersonal development.
Language communication: impaired and deviant language and communication, verbal and non-verbal -impairment in pragmatic aspects of language.
Thought and Behavior: rigidity of thought and behaviour and impoverished social imagination -ritualistic behaviour, reliance on routines, impairment of imaginative play.
DSM-IV criteria for autistic and Asperger's disorders were applied to 157 children with clinical diagnoses of Autism or Asperger's disorder . All children met the DSM-IV criteria for autistic disorder and none met criteria for Asperger's disorder, including those with normal intelligence and absence of early speech delay. The reason for this was that all children had social impairment and restricted and repetitive behavior and interests (required DSM-IV symptoms for both autistic and Asperger's disorders) and all had a DSM-IV communication impairment (which then qualified them for a diagnosis of autistic disorder and not Asperger's disorder). According to the DSM-IV, children with Asperger's disorder do not have significant cognitive or speech delays, whereas children with autistic disorder may or may not. Results suggest that early speech delay may be irrelevant to later functioning in children who have normal intelligence and clinical diagnoses of autism or Asperger syndrome and that speech delay as a DSM-IV distinction between Asperger's disorder and autism may not be justified.
Despite the availability of classification systems such as the DSM-IV-TR and the ICD-10, the diagnosis of an ASD can provide a clinician with “unique challenges” (Lord, 1997). SLTs (speech and language therapists) firstly seek information through history taking procedures. Obtaining an accurate history taking is the critical first step in determining the aetiology of a patient’s problem. Furthermore, scientists very often make diagnosis based on histories alone. During history taking, speech and language therapists ask specific questions, either of the patient or of other people who know the person and can give suitable information.
History taking may be a very comprehensive procedure. In this case several domains are examined. More specifically, history taking is divided into a number of categories. That is, parental and birth history [(e.g. Mother’s general health during pregnancy (illnesses, accidents, medications, etc.), unusual conditions that may have affected the pregnancy or birth], medical history of the child (i.e. list of any illnesses or medical conditions suffered by the child), developmental history [(i.e. the recorded developmental progress of a child (ages birth to 18 years) in such skills as sitting, walking or talking] and educational history . Last but not least social history provides SLTs with quite crucial information regarding the child. In this case, much of the information may be obtained by a social worker who works with the SLT. Healthcare social workers are invaluable resources. Generally, using a team approach can greatly assist in the acquisition of needed information and in the further care of the patient and family.
The CHecklist for Autism in Toddlers (CHAT) is a screening instrument that was devised to test the prediction that those children not exhibiting joint attention and pretend play by the age of 18 months will be at risk for receiving a later diagnosis of autism . Many SLTs use the first part (i.e. questions directed to parents) of the invaluable Check list for Autism in Toddlers (Baron-Cohen et al., 1996).
(Informal – Formal assessment)
The initial approach to the assessment of these disorders was unsystematic and unreliable, and as a consequence, structured assessment instruments were developed . Formal assessment supplements the process of clinical observation. There are many instruments used -by psychologists, SLTs, psychiatrists and others- in the identification of ASD in children and adults. Some of the most commonly used are listed below .
¨ Childhood Autism Rating Scale, (1988)
¨ Aberrant Behavior Checklist (ABC), (1980)
¨ Autism Diagnostic Interview-Revised (ADI-R), (1994)
¨ Autism Diagnostic Observation Schedule -Generic (ADOS-G) (revised and combined version of two previously used instruments, the ADOS (Lord, Rutter, Goode, & Heemsbergen, 1989) and the Pre-Linguistic ADOS (PL-ADOS; DiLavore, Lord, & Rutter, 1995)
¨ Atwood Asperger’s Syndrome Checklist
¨ ASPERGER SYNDROME CHECKLIST OF POSSIBLE BEHAVIORS (Nancy Dalrymple, PhD and Lisa Ruble, PhD.
¨ The Autism Checklist [Glynis Hannell, BA (Hons), Msc Registered Psychologist]
¨ The Asperger Syndrome Checklist [Glynis Hannell, BA (Hons), Msc Registered Psychologist]
Assessments cannot be rushed. Two or more sessions might be needed in order to obtain sufficient evidence. The environment where the assessment takes place is very crucial for the diagnostic procedure. The assessment in an unfamiliar place may not allow the child to express its potential. Apart from the official department, thorough assessment means assessment in school, house and elsewhere. During the assessment specialists should bear in mind the individual profiling (strengths and difficulties vary from person to person). Comprehensive evaluation of communication, speech and language skills consists of examination of many aspects of language. That is clinical evaluation of language fundamentals (receptive/ expressive language subtests): semantics, morphology and syntax, auditory memory etc. Moreover, standardized expressive vocabulary tests are used to define and distinguish between language delay and language disorder. There are other parameters which are included in thorough assessments. That is the examination of sensory-motor profile (orofacial examination), speech examination (phonetic-phonemic level), play assessment (symbolic play, interactive play), emotion perception tests, pragmatics profile, theory of mind stories - Sally-Anne test - and tests of problem solving (making inferences, predicting, determining causes, sequencing, problem solving).
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