Tony Attwood - Author of The Complete Guide to Asperger's Syndrome

Children

Stability and Change Among High-Functioning Children with Pervasive Developmental Disorders: A 2-Year Outcome Study

E. Starr, P. Szatmari, S. Bryson and L. Zwaigenbaum, Journal of Autism and Developmental Disabilities, Volume 33, No 1, February 2003, Pages 15 - 22.

This study prospectively compared the 2-year outcome of children diagnosed with autism or Asperger's Syndrome at age 6 - 8 years in terms of symptoms from the Autism Diagnostic Interview. Significant differences were seen in the three-domain summary scores of social interaction, communication, and repetitive activities, with the Asperger Syndrome group demonstrating fewer and/or less severe symptoms at both times. There was a trend for the Trajectories to come together over time on the socialisation and communication domains, but not the repetitive activities domain. Differences were not attributable to IQ. Analysis of individual items indicated that the autism group improved over time on seven items and showed increased symptom severity on three items. On the other hand, the Asperger's Syndrome group improved on only two items and showed increased symptom severity on six items. Results suggest that the two PDD subtypes represent similar developmental trajectories, although the Asperger's Syndrome group maintains its advantage. Educational and clinical implications of the results are discussed.

Thought Bubbles help children with autism acquire an alternative to a theory of mind

Henry M. Wellman, Simon Baron-Cohen, Robert Caswell, Juan Carlos Gomez, John Swettenham, Eleanor Toye, Kristin Lagattuta Autism, Vol 6(4) 343-363.

Children with autism have specific difficulties understanding complex mental states like thought, belief, and false belief and their effects on behaviour. Such children benefit from focused teaching, where beliefs are likened to photographs-in-the-head. Here two studies, one with seven participants and one with ten, tested a picture-in-the-head strategy for dealing with thoughts and behaviour by teaching children with autism about cartoon thought-bubbles as a device for representing such mental states. The prosthetic device led children with autism to pass not only false belief tests, but also related theory of mind tests. These results confirm earlier findings of the efficacy of picture-in-the-head teaching about mental states, but go further in showing that thought-bubble training more easily extends to children's understanding of thoughts (not just behaviour) and to enhanced performance on several transfer tasks. Thought-bubbles provide a theoretically interesting as well as an especially easy and effective teaching technique.

The theory of mind hypothesis for autism proposes that a central cognitive deficit for individuals with autism is an impairment in using mental state concepts. Mental state concepts such as a person's beliefs, knowledge, desires, and intentions, ordinarily allow us to understand our own and other's lives ('She doesn't know the song'), to predict behaviour ('She'll sing the wrong tune'), to interact socially ('To make her happy I'll choose a different song'), and to communicate ('She doesn't know that song, I'd better tell her the words'). Difficulties in understanding and using mental state concepts may therefore underlie the difficulties in social interaction and communication in autism. Most children with autism with mental ages well beyond 4 years have difficulties with tasks testing understanding of emotions, knowledge and ignorance, deception, and the mental-physical distinction, although these tasks are normally solved by 3- and 4-year-olds. The theory of mind deficit for autism has inspired possible training interventions for children with autism.

To overcome this problem, two recent studies have attempted to teach children with autism a more conceptually intriguing, picture-in-the-head strategy, to aid an understanding of mental states. Swettenham et al. and McGregor et al. al. both used training sessions where photographs were slotted into a manikin's head or a doll's head and children were told, 'When a person looks at something, they make a sort of a picture in their head'. Thoughts, including false thoughts, were thus portrayed as actual pictures inside a head.

In the present study we extend a general picture-in-the-head approach using a very different pictorial analogy: thought-bubbles. Thought-bubbles arguably provide a particularly natural or effective way of depicting thoughts pictorially, one that could come to aid autistic individuals reasoning about people, behaviour, and mental states. Such a strategy should provide a device for thinking about thoughts, and to be most effective should be based on cognitive abilities or skills known to be intact in individuals with autism.

The theoretical rationale for exploring a picture-in-the-head strategy receives some indirect, empirical support from a study by Hulburt et al. They elicited reports of inner experience (sampled during everyday activities) from three individuals with Asperger's Syndrome. These individuals consistently described only their perceptions and actions, devoid of thoughts, emotions, or inner speech. To the extent that they described inner experiences at all, however, they described them solely in terms of pictures in their head. Typical controls described a complex mixture of inner speech, emotional reactions, mental images, and pure thought.

Thought-bubbles are somewhat naturally occurring in that they, and relatedley speech-bubbles, appear in comics, cartoons, and sometimes in children's books. Moreover, 3-and 4- year-old normally developing children easily understand thought-bubbles as depictions of 'what the person is thinking', even in the case of mistaken thoughts or two people having different thoughts about exactly the same object.

False belief tasks come in at least two different forms. One, as in the Sally-Anne task, focuses on false beliefs created by a change of location. A second, captured in classic smarties tasks concerns beliefs about unexpected contents (a Smarties candy box that is opened to reveal pencils, not candy in it).

We do not want to give the false impression that thought-bubble instruction works effectively or easily with all children with autism, or even all relatively able children with autism of the sort we worked with. Several of the children we worked with learned very little. For several others, as noted, progress required creative tailoring to the child's skills, preoccupations, and limits (as well as teaching persistence).

A cognitive behaviour therapy intervention for anxiety in children with Asperger's Syndrome

Kate Sofronoff and Tony Attwood Good Autism Practice, Volume 4, (2003) pp 2-8.

Sixty-five children aged between 10 and 12 years of age took part and their parents were involved in this work to differing degrees. Measures were taken on three occasions, pre-intervention, immediately post-intervention and at 6-week follow up. Two forms of the intervention were compared, one in which only the children participated but parents were given written material and a second, in which parents were taught all strategies and information in the same manner as the children. The intervention groups were compared with a waiting-list control group.

Strategies to manage anxiety
Strategies and techniques initially developed for children with autism have been used with some success with children with Asperger's Syndrome (eg Social Stories and Comic Strip Conversations (Gray, 1998)). The intervention described in this paper, however, was developed specifically for children with Asperger's Syndrome and has its basis in the sound theoretical framework of Cognitive Behaviour Therapy (CBT). The aim of the intervention was to work with children experiencing significant anxiety to teach them effective strategies to manage their feelings and to encourage a broadening of their emotional and behavioural repertoire.

Parents as co-therapists
A second and equally important aim of the intervention was to work with parents to encourage them to act as co-therapists for their children. This is an especially important component because without the assistance of parents it is unlikely that the child will generalise strategies learned within sessions to other situations and locations. We also anticipated that involving parents in the program would lead to an increase in parental self-efficiency in the management of common behavioural problems. Following the intervention we actively sought feedback from parents both about the program itself and about any changes they were able see, either positive or negative, in their child.

The development and maintenance of friendship in high-functioning children with autism

Nirit Bauminger and Cory Shulman Autism, Vol 7 (1) pp 81 - 97.

The current study investigated mothers' perceptions of the development of friendship in high-functioning children with autism and in typically developing children. Fourteen mothers in each group (autism, typical) completed the Childhood Friendship Survey regarding their children's friendships. Main results indicated that both groups (autism and typical) tended to have same-gender and same-age friendships. However, friendships of children with autism differ compared with typical children's friendships on a number of friends, friendship durations, frequency of meetings, and type of activities. Half of the friendships in the autism group were mixed (friendship with a typically developing child). Mixed differed from non-mixed friendships in that mixed pairs met and played mostly at home, whereas non-mixed pairs met and played at school. Factors contributing to the development and formation of friendship in each group are discussed.

Psychosocial functioning in a group of Swedish adults with Asperger's Syndrome or high-functioning autism, I. Engstrom, Ekstrom, B. Emilsson, Autism, Vol 7 (1), pp 99-110.

This study reports on psychosocial functioning in Swedish adults with Asperger's Syndrome (AS) or high-functioning autism (HFA). A systematically selected sample of patients and relatives was interviewed concerning their psychosocial situation. The majority was living independently. All persons but one were unemployed. None was married and none had children. Only a few had some kind of partner. Most persons needed a high level of public and/or private support. The overall adjustment was rated good in 12 per cent, fair in 75 per cent and poor in 12 per cent. Adult persons with AS/HFA have extensive need for support and their families and/or society. This information is important in order to provide adequate interventions that are in accordance with the expressed needs of the individuals themselves.

Cognitive Behavioural treatment of obsessive-compulsive disorder in a child with Asperger's Syndrome: A Case Report

Judy Raven, Susan Hepburn Autism, Vol 7 (2) pp 145-164.

This case report outlines the cognitive-behavioural treatment of obsessive-compulsive disorder in a 7-year-old female with Asperger's Syndrome. Interventions were based upon the work of March and Mulle and were adapted in light of the patient's cognitive, social, and linguistic characteristics. Obsessive-compulsive symptoms improved markedly after approximately 6 months of treatment. Issues regarding symptom presentation, assessment, and treatment of a dually diagnosed patient are discussed.