Friday, September 21, 2012

Autism and Savant Syndrome

What are “savant skills?”
There is a long history of reports of individuals who despite having severe intellectual impairments, demonstrate remarkable skills in a particular area. The term “savant” has been variously defined as those individuals who show (a) normatively superior performance in an area and (b) a discrepancy between their performance in that area and their general level of functioning. Some researchers have differentiated “prodigious” savants (e.g., individuals possessing an exceptional ability in relation to both their overall level of functioning and the general population) from “talented” savants (e.g., individuals showing an outstanding skill in comparison with their overall level of functioning). Savant skills have been reported much more frequently in males than in females and have been identified in a wide range of neurological and neurodevelopmental disorders. The most commonly reported savant skills are mathematical skills (calendrical calculations, rapid arithmetic and prime number calculations), music (especially the ability to replay complex sequences after only one exposure), art (complex scenes with accurate perspective either created or replicated following a single brief viewing) and memory for dates, places, routes or facts. Less frequently reported are “pseudo-verbal” skills (hyperlexia or facility with foreign languages), coordination skills and mechanical aptitude.
Although there have been many single case or small group studies of individuals with autism who possess savant abilities or exceptional cognitive skills, there have been few systematic, large-scale investigations in this area. Inconsistencies in definition and wide variation in diagnostic criteria, ages and ability levels of the cases reported are problematic, as is a paucity of valid information on rates of savant skills in ASDs. The objective of this research study was to investigate the nature and frequency of savant skills in a large sample of individuals with autism who had been initially diagnosed as children.
The total sample was comprised 137 individuals, first diagnosed with autism as children, who were subsequently involved in an ongoing, longitudinal follow-up study. Cognitive assessments (Wechsler Scales) were completed for all participants (100 males and 37 females) between the ages of 11 and 48 years (mean age of 24). Parental report data on savant skills were obtained approximately 10 years later at a subsequent follow-up.  Cognitive ability ranged from severe intellectual impairment to superior functioning. Savant skills were judged from parental reports and specified as “an outstanding skill/knowledge clearly above participant’s general level of ability and above the population norm.”
Of the 93 individuals for whom parental questionnaire and cognitive data were available, 16 (17.2%) met criteria for a parent-rated skill, 15 (16.8%) had an exceptional cognitive skill and 8 (8.6%) met criteria for both. There were 14 calendrical calculators (one also showed exceptional memory and another also showed skill in computation and music). There were four others with computational skills (in one case combined with memory and in another case with music). Visuospatial skills (e.g., directions or highly accurate drawing) were reported in three individuals. One individual had a musical talent, one an exceptional memory skill and one had skills in both memory and art. The subtest on which participants were most likely to meet the specified criteria for an area of unusual cognitive skill was block design followed by digit span, object assembly and arithmetic.
There was a sex difference (albeit statistically non-significant) in the prevalence of savant skills. Almost one-third (32%) of males showed some form of savant or special cognitive skill compared with 19 percent of females. No individual with a non-verbal IQ below 50 met criteria for a savant skill and contrary to some earlier hypotheses; there was no indication that individuals with higher rates of stereotyped behaviours/interests were more likely to demonstrate savant skills.
In total, 39 participants (28.5%) met criteria for a savant skill. Cognitively, 23 individuals (17% of total sample) met criteria for one or more exceptional area of skill on the Wechsler Scales. Combining the two, 37 per cent of the sample showed either savant skills or unusual cognitive skills or both, a far higher proportion than previously reported. These results suggest that the rates of savant skills in autism are significant, particularly among males, and although these estimates are higher than reported by other researchers, the findings parallel those of previous studies. Based on these findings, it appears likely that at least a third of individuals with autism show unusual skills or talents that are both above population norms and above their own overall level of cognitive functioning. However, these data offer no support to claims that savant skills occur most frequently in individuals with autism who are intellectually impaired or that individuals with higher rates of stereotyped behaviors/interests were more likely to demonstrate savant skills.
Apart from the need for further research examining the underlying basis of savant skills and why certain individuals go on to develop any area of exceptional skill and why these skills encompass such different areas, there is a more practical and pressing question; “how can these innate talents be developed to form the basis of truly ‘functional’ skills?” In the present study, only five individuals with exceptional abilities (four related to math and one related to visuospatial ability) had succeeded in using these skills to find permanent employment. For the majority, the isolated skill remained just that, leading neither to employment nor greater social integration. As the authors conclude, “The practical challenge now is to determine how individuals with special skills can be assisted, from childhood onwards, to develop their talents in ways that are of direct practical value (in terms of educational and occupational achievements), thereby enhancing their opportunities for social inclusion as adults.”
Howlin, P., Goode, S., Hutton, J., & Rutter, M. (2009). Savant skills in autism: Psychometric approaches and parental reports. Phil. Trans. R. Soc. B, 364, 1359–1367
Lee A. Wilkinson, PhD, CCBT, NCSP is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers.

Wednesday, September 19, 2012

Interventions for Adolescents and Young Adults with Autism Spectrum Disorder (ASD)

Although it would seem obvious that children with ASD will eventually transition to adolescence and adulthood, there is a paucity of information about effective interventions for these age groups compared to data for younger children. Even though the core symptoms of ASD (impairments in communication and social interaction and restricted/repetitive behaviors and interests) may improve overtime with intervention for many individuals, some degree of impairment typically remains throughout the lifespan.  Consequently, the focus of intervention/treatment must shift from remediating core deficits in childhood to promoting adaptive behaviors that can facilitate and enhance ultimate functional independence and quality of life in adulthood. This includes new developmental challenges such as independent living, vocational engagement, post-secondary education, and family support. Unfortunately, there is evidence to suggest that improvements in symptoms and problem behaviors may decrease or end once youth with ASD transition from school-based programs. This is likely due, at least in part, to the termination of services received through the secondary school system upon exiting from high school, as well as the lack of adult services. The lack of services available to help young adults with ASD transition to greater independence has been noted by researchers for a number of years and has become an increasingly important issue as the prevalence of ASD continues to grow and as children identified with ASD reach adolescence and adulthood.
Comparative Effectiveness Review
What are the effects of currently available interventions/treatments on adolescents and young adults with ASD?  To answer this question, researchers at the Vanderbilt Evidence-based Practice Center systematically reviewed evidence on therapies for adolescents and young adults (ages 13 to 30) with autism spectrum disorders (ASD). Their review focused on the outcomes, including harms and adverse effects, of interventions addressing the core symptoms of ASD; common medical and mental health comorbidities occurring with ASD; the attainment of goals toward functional/adult independence; educational and occupational/vocational attainment; quality of life; access to health and other services; and the transitioning process (e.g., process of transitioning to greater independent functioning). Researchers also addressed the effects of interventions on family outcomes including parent distress and satisfaction with interventions.
Of more than 4,500 studies on autism interventions published between 1980 and 2011, only 32 focused on interventions/therapies for individuals ages 13 to 30. Most of the studies available were of poor quality, which may reflect the relative recency of the field. Five studies, primarily of medical interventions, had fair quality. Behavioral, educational, and adaptive/life skills studies were typically small and short term and suggested some potential improvements in social skills and functional behavior. Small studies suggested that vocational programs may increase employment success for some individuals. Few data are available to support the use of medical or allied health interventions in the adolescent and young adult population. The medical studies that have been conducted focused on the use of medications to address specific challenging behaviors, including irritability and aggression, for which effectiveness in this age group is largely unknown and inferred from studies including mostly younger children. However, antipsychotic medications and serotonin reuptake inhibitors were associated with improvements in specific challenging behaviors. Similarly, little evidence supports the use of allied health interventions including facilitated communication.
Despite an increasing population of adolescents and young adults identified with an ASD and the need for effective intervention across the lifespan, very few studies have been conducted to assess treatment approaches for adolescents and young adults with ASD. Moreover, the available research is lacking in scientific rigor. As a result, there is little evidence available for specific treatment approaches in this population; especially for evidence-based approaches to support the transition of youth with ASD to adulthood. In particular, families have little in the way of evidence-based approaches to support interventions capable of optimizing the transition of teens with autism into adulthood. Research is needed across all intervention types on which outcomes to use in future studies. “Overall, there is very little evidence in all areas of care for adolescents and young adults with autism, and it is urgent that more rigorous studies be developed and conducted,” commented Melissa McPheeters, director of Vanderbilt’s Evidence-Based Practice Center and senior author of the report. “There are growing numbers of adolescents and adults with autism in need of substantial support. Without a stronger evidence base, it is very hard to know which interventions will yield the most meaningful outcomes for individuals with autism and their families,” said Zachary Warren of Vanderbilt who also contributed to the report.
Lounds Taylor J, Dove D, Veenstra-VanderWeele J, Sathe NA, McPheeters ML, Jerome RN, Warren Z. Interventions for Adolescents and Young Adults With Autism Spectrum Disorders. Comparative Effectiveness Review No. 65. (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2007-10065-I.) AHRQ Publication No. 12-EHC063-EF. Rockville, MD: Agency for Healthcare Research and Quality. August 2012. 
The complete report is available at:  
Lee A. Wilkinson, PhD, CCBT, NCSP is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers. He is also the editor of a recent volume in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools and author of the new book, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT.

Thursday, September 6, 2012

Mindblindness and Autism

What is Mindblindness?
Empathizing; Mentalizing; Mindreading; Perspective taking; Theory of mind
The inability to attribute mental states such as thoughts, desires, knowledge, and intentions to self and others, and to make sense of and predict another person’s behavior.
Mindblindness theory proposes that children and adults with autism spectrum disorders are delayed in the development of what is termed “theory of mind” (ToM). ToM is a cognitive (attribution) component of empathy; the ability to identify cues that indicate the thoughts and feelings of others and “to put oneself into another person’s shoes.” It is also referred to as “mentalizing,” “mindreading,” and “perspective taking.” The ability to reflect on one’s own and other people’s minds (beliefs, desires, intentions, imagination and emotions) allows us to interact effectively with others in the social world. Typical individuals are able to mindread relatively easily and intuitively. For example, we can read a person’s facial expression and body language, and tone of voice and recognize his or her thoughts and feelings, and the likely course of behavior. In other words, we interpret, predict, and participate in social interaction automatically, and for the most part, instinctively. This attribution of mental states is a fundamental component of social interaction and communication. An impairment in ToM results in an inability to appreciate other people’s emotions and thoughts, and to make sense of or predict another’s actions. As a consequence, the person with impaired ToM is said to have a form of “mindblindness” or a deficit in “empathizing” ability.
Relevance to Autism:
The concept of ToM and mindblindness has been widely studied over the past two decades and used to explain the development of social cognition and the core social deficits of developmental disorders such as autism. The understanding of other people’s mental states develops early in life and becomes more complex with advancing age. Research suggests that typically developing children, in contrast to those with autism, are born with a set of skills which enable them to comprehend and respond to other people’s mental states and feelings. For example, children can understand relationships between mental states by 3 years of age. By age four, they can understand that people can hold false beliefs (deception). Typical children at age seven begin to understand what not to say to avoid offending others. A typical 9 year old can interpret another person’s facial expressions and figure out what they are thinking or feeling. It is a deficit in this normal process of ToM or empathizing that has the potential to explain the lack of pretend play and the core social and communication problems diagnostic of children with autism. Children with autism are said to lack an effective ToM and thus, have a form of mindblindness. The mindblindness theory has been broadened to include an affective component (emotional reactivity) and a second factor termed systemizing to explain the non-social areas of strength often demonstrated by individuals with autism spectrum conditions. Children with ToM impairment frequently experience academic, behavioral, and emotional problems related to their social skills deficits. Indeed, impairments in social reciprocity are one of the defining characteristics of autism spectrum disorders. Consequently, interventions focusing on social adaptive skills are critically important to the treatment of this group of children. While the research on the effectiveness of social skills intervention is still in the formative stage, several programs have been developed to promote prosocial behavior and expand ToM abilities among children with autism spectrum disorders. They include: social stories, computer programs such as Mind Reading: The Interactive Guide to Emotions and The Transporters; ToM teaching programs; and social skills programming.
Wilkinson, L. A. (2011). Mindblindness in Encyclopedia of Child Behavior and Development, Part 13, 955-956, DOI: 10.1007/978-0-387-79061-9_1795
Lee A. Wilkinson, PhD, CCBT, NCSP is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers. He is also the editor of a new Volume in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools.

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