Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 31: Child Psychiatry

Congenital Deafness or Hearing Impairment Because children with autism spectrum disorder may appear mute or lack language development, congenital deafness and hearing impairment must be considered and ruled out. Dif- ferentiating factors include the following: infants with autism spectrum disorder may babble only infrequently, whereas deaf infants often have a history of relatively normal babbling that then gradually tapers off and may stop at 6 months to 1 year of age. Deaf children generally respond only to loud sounds, whereas children with autism spectrum disorder may ignore loud or normal sounds and respond to soft or low sounds. Most importantly, audiogram or auditory-evoked potentials indicate significant hearing loss in deaf children. Deaf children usually seek out nonverbal social communication with regularity and seek social interactions with peers and family members more consistently than children with autism spectrum disorder. Psychosocial Deprivation Severe neglect, maltreatment, and lack of parental care can lead children to appear apathetic, withdrawn, and alienated. Lan- guage and motor skills may be delayed. Children with these signs generally improve when placed in a favorable and enriched psychosocial environment, but such improvement is not the case with children with autism spectrum disorder. Course and Prognosis Autism spectrum disorder is typically a lifelong, albeit hetero- geneous, disorder with a highly variable severity and prognosis. Children with autism spectrum disorder and IQs above 70 with average adaptive skills, who develop communicative language by ages 5 to 7 years, have the best prognoses. A longitudinal study comparing symptoms in children with high-IQ autism spectrum disorder at the age of 5 years, with their symptoms at age 13 through young adulthood, found that a small proportion no longer met criteria for autism spectrum disorder. Most of these youth demonstrated positive changes in communication and social domains over time. Early intensive behavioral inter- ventions have been found to provide a profound positive impact on many children with autism spectrum disorder, and in some cases lead to recovery and function in the average range. The autism spectrum disorder symptom areas that do not seem to improve substantively over time with early behavioral interventions are related to ritualistic and repetitive behaviors. However, currently, evidence-based behavioral interventions specifically targeting repetitive behaviors may ameliorate them. The prognosis of a given child with autism spectrum disorder is generally improved if the home environment is supportive. Treatment The goals of treatment for children with autism spectrum disor- der are to target core behaviors to improve social interactions, communication, broaden strategies to integrate into schools, develop meaningful peer relationships, and increase long-term skills in independent living. Psychosocial treatment interven- tions aim to help children with autism spectrum disorder to develop skills in social conventions, increase socially accept-

able and prosocial behavior with peers, and to decrease odd behavioral symptoms. In many cases, language and academic remediation are also required. In addition, treatment goals gen- erally include reduction of irritable and disruptive behaviors that may emerge in school and at home and may exacerbate during transitions. Children with intellectual disability require devel- opmentally appropriate behavioral interventions to reinforce socially acceptable behaviors and encourage self-care skills. In addition, parents of children with autism spectrum disorder often benefit from psychoeducation, support, and counseling in order to optimize their relationships and effectiveness with their children. Comprehensive treatment for autism spectrum dis- order including intensive behavioral programs, parent training and participation, and academic/educational interventions have provided the most promising results. Components of these com- prehensive treatments include expanding social skills, commu- nication, and language, often through practicing imitation, joint attention, social reciprocity, and play in a directed but child-cen- tered manner. Five randomized controlled trials (RCTs) of early intensive comprehensive behavioral interventions targeting core features of autism spectrum disorder in children ranging in age from 2 years to 5 years of age have shown increases in language acquisition, social interactions, and educational achievement at the end of the study period compared to control groups. The study periods ranged from 12 weeks to several years, and the settings were at home, in clinic, or at school. The comprehensive treatment models or adapted versions of them were used either alone or in combinations in these RCTs as described below. 1. UCLA/Lovaas-based Model. This intensive and manual- ized intervention primarily utilizes techniques derived from applied behavior analysis, which is administered on a one- to-one basis for many hours per week. A therapist and a child will work on practicing specific social skills, language usage, and other target play skills, with reinforcement and rewards provided for accomplishments and mastery of skills. 2. Early Start Denver Model (ESDM) Interventions are administered in naturalistic settings such as in day care, at home, and during play with other children. Parents are typi- cally taught to be co-therapists and provide the training at home while educational settings also provide the interven- tions. The focus of the interventions is on developing basic play skills and relationship skills, and applied behavior anal- ysis techniques are integrated into the interventions. This approach is focused on training for very young children and is applied within the context of the child’s daily routine. 3. Parent Training Approaches This includes Pivotal Response Training, in which parents are taught to facilitate social and communication development within the home and during activities by targeting gateway or pivotal social behaviors for mastery by the child with the expectation that once these central social skills were mastered, a natural gen- eralizing of social behaviors would follow. Extensive parent and family components are integrated into this type of inter- vention. Other parent training approaches focus on language Psychosocial Interventions Early Intensive Behavioral and Developmental Interventions