Eating Disorders in Autistic Children And Effectiveness of FloorTime Behavioral
The proposal will address the statement Autistic children treated with the FloorTime technique experience fewer inappropriate eating related behaviors than those who are not treated with this method. This proposal has implications, which should foster continued research using other established behavioral modification strategies, which could eventually mitigate the problem of eating disorders among nonverbal and verbal autistic children.
Chapter 1 Introduction
Autism is defined as the presence of markedly abnormal or impaired development in social interaction and communication and a markedly restricted repertoire of activity and interest. There may be marked impairment in the use of multiple nonverbal behaviors to regulate social interaction and communication (American Psychiatric Association, 2006). It is estimated that three to six out of every 1000 children develop autism, which is generally diagnosed by age 3 (Johnson, Myers, Council on Children With Disabilities, 2007).
In a report published in 2006, the cost to taxpayers and families of autistic individuals could run as high as 3.2 million over his or her lifetime (Ganz, 2007) and families of autistic children spend 39,000 to nearly 130,000 of personal funds annually to combat the problem (Hagedorn, Montaquila, Carver, ODonnell, Chapman, 2006). Despite decades of research there still appears to be disagreement among researchers as to the cause of the problem and the best solutions to deal with it.
Many approaches to treating Autism have been suggested including behavior treatments and communication therapies, educational therapies and drug therapies (Pellicano, Jeffery, Burr, Rhodes, 2007). These treatments attempt to target specific behaviors of the autistic child with an aim at increasing appropriate social behavior in the school and at home (Tsermentseli, OBrien, Spencer, 2008). Unfortunately, none of these approaches alone provides a total solution for all maladaptive behavior.
The present study will attempt to evaluate a popular strategy, FloorTime (Greenspan Weider, 2006), and its effectiveness when paired against such maladaptive behaviors as self-injurious behavior (SIB e.g., head banging biting hands, arms or forearms and hand slapping of the legs and thighs), physical aggression toward parents, siblings, other students, and spitting (Richler, Bishop, Kleinke, Lord, 2007). These behaviors relate to eating behavior problems (the antecedent) among nonverbal children with autism (Martins, Young, Robson, 2008 Williams Foxx, 2007).
Chapter 1 will present an overview of the study supporting the relevance and importance of research in this field. This proposal will provide statistics to substantiate the research and define key terms including a brief overview of the literature. Additionally, in Chapter 1, variables and constructs will be identified, the methodology and research criteria will be presented and a summation will be provided at the end of the chapter.
Background
Children with Autism may have sensory sensitivities, which can affect their eating habits. Their food selection is often based on the texture of the food rather than the taste. When new food textures are introduced, maladaptive behaviors can occur. Poor nutrition leads to improper cognitive development, less than optimal physical weight and vitamin deficiency (Office for National Statistics, 2009). When the child is encouraged to consume a different food from the preferred food, maladaptive behaviors are manifested (Mottron, Dawson, Soulieres, Hubert, Burack, 2006).
Autistic children require a significant degree of management (Klin, Lin, Gorrindo, Ramsay, Jones, 2009). The effective management of maladaptive behavior in autistic children requires reliable solutions and viable behavior strategies. When searching for ways to eliminate poor behaviors, parents, teachers and therapist are often overwhelmed with the numerous approaches available (Johnson et al., 2007). Seeing the need for immediate action, often the selected approach results in frustration, financial costs (private and government) and little to no measureable results (Ganz, 2007).
Conversely, maladaptive behavior in young children, that remains unchecked, provides a foundation for the expansion of more severe behavior later in life. Such as acts of defiance and violence, which includes physical assaults or personal physical attacks, inappropriate touching, public mastubation, etc., are all considered socially unacceptable by the general population (Gallese, 2006). Although behavior modification is welcomed in most cases, the therapist must remain cognizant of the implications associated with strategies which restrict or limit the childs freedoms. The therapist must also be aware that the introduction of a new behavior paradigm may trigger increases in unwarranted behaviors (Pelphrey, Morris, McCarthy, LaBar, 2007). Autism children as a population are set on routine schedules. When any change to that routine is introduced, maldaptive behaviors ensue as a form of resistance to the introduction of a change.
Since eating disorders run high among special needs populations, several approaches are available which may assist in changing this maladaptive behavior in autistic children. When selecting an approach to use in an attempt to modify a childs behavior the parent andor therapist must select an appropriate strategy to meet the childs needs (Pelphrey et al., 2007). One child may require high intensity training yet the same level would over-stimulate a different child. No single approach is right for every child. Therapists and teachers may be unaware of the various strategies used to modify the behavior of autistic children (Cooper, Robinson, Patall, 2006).
None of the strategies in or of themselves provide a total solution for all maladaptive behaviors. Some of these strategies include Discreet Trials (Lovaas, 2006), Applied Behavior Analysis (Cooper, Heron, Heward, 2007), FloorTime, (Greenspan Weider, 2006), Pivotal Response Training (Koegel Koegel, 2006), Functional Communication Training (Mancil, 2006) and the Treatment and Education of Autistic and related Communication handicapped Children (Mesibov, Shea, Schopler, 2005). A few of these strategies will be reviewed in chapter two.
For the purpose of this proposal, the FloorTime method (Greenspan Weider, 2006) will be used in the treatment of eating disorders for autistic children. Severe to profound mental retardation and children with Asperger diagnosis will be excluded from this trial, as that would require much more professional approach in handling such children. A study was conducted using this method which has proven effective in improving a childs empathetic, creative and reflective, with healthy peer relationships and solid academic skills (Todd, Campbell, Meyer, Horner, 2008). While the effectiveness of using this method in the area of creativity and academic skills is well documented, not much is known about its effectiveness in modifying eating related inappropriate behaviors in autistic children.
Problem Statement
About 25 of all children in US are reported to have some form of feeding disorder. These eating disorders include food refusal, food fads, overeating, failure to thrive, anorexia nervosa and pica (Bluford, Sherry, Scanlon, 2007). Children with Autism, as compared with other children, generally have food avoidance behaviors and fear of unfamiliar foods or neophobia. Martins et al. (2008), contend that such children display signs of control over feeding behavior by consuming what they desire and rejecting what they dont. Texture of the food like its softness, hardness or smooth nature and smell of the food like sweet, spicy, bland or robustness affects the eating behaviors of such children. Appearance of the food can also determine whether the child will or will not consume it.
For example, color or arrangement of the food on plate or bowl can prove to be detrimental factors in their food habits. They may become obsessed with one or more particular types of food such as chips, bread, or French fries.
Parents and caregivers of autistic children who develop eating disorders should seek early intervention as delays in intervention could lead to serious risk and complication like malnourishment and vitamin deficiency (Moffitt, 2006). This proposal will conduct trials, which will address the effectiveness of the use of FloorTime (Greenspan Weider, 2006) in dealing with inappropriate behaviors related to eating among autistic children.
Purpose Statement
The intent of the proposed quantitative study is to determine if the method of behavior modification called FloorTime can help autistic children expand their limited food selection. The current research will attempt to address the statement The FloorTime technique significantly decreases the frequency of (inappropriate) eating behaviors among autistic children.
The proposed study will measure the effects of the FloorTime intervention upon the inappropriate eating related behaviors in children. This strategy will be used to compare the effects of FloorTime intervention, upon the specific, measurable, and inappropriate eating related variables, among several autistic children. The proposed study will be conducted through the use of a quasi-experimental method of research and a one way within subjects ANOVA with intervention (treatment versus control) as the independent variable, and the dependent variable as frequency of inappropriate eating behaviors.
The proposed study will review baseline data of specific eating related inappropriate behaviors of these subjects. Quantitative research constructs include The maladaptive behavior of Autistic children and relevance of the FloorTime as a behavior modification strategy in a treatment modality, which will address the gradations of behavior modification, the degree of efficacy of the technique used and challenges associated with this strategy. Extraneous variable include extinction bursts where behaviors may get worse before they get better or which may re-emerge under novel or challenging circumstance (Trosclair, Lerman, Call, Addison, Kodak, 2008). Targeted population for this trial will be autistic children ranging in age from 5 to 8 years old with mild to moderate behavior problems (as measured by the Childhood Autism Rating Scale, Second Edition, (Schopler, Bourgondien, Wellman, Love, 2010), and the Wechsler Intelligence Scale for Children Fourth Edition (Wechsler, 2003). An existing diagnosis of autism as substantiated by a licensed practitioner (psychiatristpsychologist) and maladaptive behavior as observed by the caregiver (parents) are the qualifiers for this trial. The participants used cannot be randomly assigned from among all autistic children, but will be assigned from the available residential locations of a home based treatment program designed to treating autistic children. The entire study will attempt to conduct all research in the natural residential setting for the child. The targeted geographical location of the study is Northern Virginia, including the counties of Alexandria, Fairfax, Prince William County, Arlington, Stafford and Loudon.
Theoretical Framework
Autistic disorder (also called autism) is a neurological and developmental disorder that usually appears during the first three years of life (APA, 2006). Approximatelyone in 150 childrenis diagnosed with Autism Spectrum Disorder (American Academy of Pediatrics, 2007). Autism is much more prevalent in boys than girls, with four times as many boys affected than girls (Allen, 2005). Lacking social awareness, children with autism appear to live in their own world, demonstrating little interest in others. Autistic children often have problems in communication, avoid eye contact, and show limited attachment to others (Schreck Williams, 2006).
Studies carried out on adolescent girls have also indicated typical eating behavioral traits like crying, refusal to eat etc. Adolescent girls with Asperger Syndrome are at a higher risk of developing eating problems than a compatible population of girls who have not developed Asperger Syndrome (Kalyva, 2009). Children with Autism typically are ritualistic in their approach to mealtime, wanting the same eating utensils and desiring food to be prepared in the same way each time (Williams, Gibbons, Schreck, 2005).
Most professionals in this field concur that early intervention is vital to the future success of the child. Invariably, early intervention increases the likelihood that the autistic child may function at the level of his peers (Buckley, Strunck, Newchok, 2005). Recently, the American Academy of Pediatrics published new Early Screening Guidelines to help identify children in need of early intervention (American Academy of Pediatrics, 2007).
Citing a comprehensive study on malnutrition during the early years of life, Barker Maughan (2009) indicate that antisocial and aggressive behaviors were manifested particularly during ages 4 to 13. According to the study, mothers who drank alcohol, smoked cigarettes during pregnancy and who experienced maternal depression, cruelty and anxiety, often did not receive proper prenatal care and birthed children who showed an increase in violent and antisocial behavior by age 13.
FloorTime
FloorTime in general is considered a very useful model for clinicians, parents, and educators to assess the developmental needs of children and their families. The model proves far more helpful in case of children with special needs. This model is a result of integration of research studies in different disciplines like occupational therapy, social work, and marriage, family therapy and speech and language pathology (Greenspan Weider, 2006). This proposed study will test the validity of FloorTime in managing the maladaptive behaviors associated with demands placed on children to eat foods beyond their taste preferences. FloorTime technique (Greenspan Weider, 2006) revolves around a concept called FloorTime -- time which the caregivers, generally the parents, spend entering the childs activities and following the childs lead (Greenspan et al, 2006). If the child wants to line up cars in a row or twirl a top, the parents will join the child in his or her preferred activity with the intent of developing this action into an affective interaction) rather than demanding that the child join them in their preferred activity (a process which, at best, will produce no more than rote action and reaction (Greenspan Weider, 2006). Starting with this mutual, shared engagement, the parents are assisted to draw the child into increasingly more complex interactions, a process known as opening and closing circles of communication. For example, the parent may begin to take turns with the child who is lining up his cars, until the child begins to expect and wait for his parents turn. Then, the parent may accidentally place a car in the wrong spot, tempting the child to open and close a circle of communication as he corrects this appalling error.
FloorTime (Greenspan Weider, 2006), behavior modification techniques are widely used to help modify inappropriate behaviors in autistic behaviors (Carcani-Rathwell, Rabe-Hasketh, Santosh, 2006). The use of this approach presents specific challenges, however. First, one of the characteristics of the autistic child is an attachment to habits and routines (Evans, Canavera, Kleinpeter, Maccubbin, Taga, 2005). This modification technique represents a change in routine and habits and may thus elicit an initial negative response (Iarocci McDonald, 2006). Another challenge is tailoring the behavior modification program to the specific needs of the child (Linscheid, 2006).
Research Question and Hypotheses
The autistic child experiences a range of behavior and social problems. Foremost among these are eating related behaviors, as proper nutrition is key to physical health which in turn further effects behavior. In particular, autistic children may be sensitive to a particular aspect of food, such as color, texture, and appearance, and typically refer repetitive rather than new experiences, leading them to fixate on eating a specific food and thus limiting their nutritional opportunities. Introducing new foods is often problematic, and can evoke inappropriate eating related behaviors such as spitting out the food, kicking and self injurious behaviors. These behaviors not only affect their eating at the time the food is introduced, but can upset the children and carry over into post feeding mood and behavior.
Behavior modification techniques often aim at eliminating inappropriate behaviors in general and can reasonably be assumed to have potential benefit in the treatment of inappropriate eating related behaviors. The proposed study will research the question and hypotheses as follows
Q1 To what extent does the FloorTime technique significantly decrease the frequency of inappropriate eating behaviors among a select group of autistic children ranging in age from 5 to 8 years
Ho There is no significant decrease in inappropriate eating behaviors over a 3- week period for the select group of autistic children aged 5 to 8 years, treated with the FloorTime technique when compared to autistic children not treated with this intervention.
Ha There is significant decrease in inappropriate eating behaviors over a 3- week period for the select group of autistic children aged 5 to 8 years, treated with the FloorTime technique when compared to autistic children not treated with this intervention.
Nature of the Study
The proposed research will use a quantitative, quasi-experimental design to measure the effects of the FloorTime intervention (Greenspan Weider, 2006) upon the inappropriate eating related behaviors in children. The proposed study will be conducted through the use of a quasi-experimental method of research and a one way within subjects ANOVA with intervention (treatment versus control) as the independent variable, and the dependent variable as frequency of inappropriate eating behaviors. No random assignment can be done for practical reasons. Quantitative research constructs will include the maladaptive behavior of Autistic children and relevance of congruent behavior modification strategies in a treatment modality. Extraneous variable include extinction bursts where behaviors may get worse before it gets better or which may re-emerge under novel or challenging circumstance (Trosclair et al., 2008).
Significance of the Study
It is equally important to understand that children with Autism have maladaptive behavior episodes (Linscheid, 2006). At times this behavior may be a side affect from medication, may have a genetic basis or may be the result of external factors such as agitation, loud noises and other environmental frustrations (Schaaf Nightlinger, 2007), which may, in turn, manifest the resultant maladaptive behavior when the child is asked to perform various challenging tasks.
Finding a suitable behavior modification technique requires trial and error and depending on the child, may or may not be effective (Smith, Press, Koenig Kinnealey, 2005). The use of one strategy may not prove beneficial alone and may require the use of more than one (Tomchek Dunn, 2007).
This study will attempt to provide parents, teachers, therapist and others who deal with autistic children with information on how to deal with the important problem of eating related inappropriate behaviors in autistic children. Specifically, it will establish whether or not FloorTime technique (Greenspan Weider, 2006) is a useful tool in this regard.
Definitions
Listed below are definitions that are common to this proposed study topic but may not be universally understood
Applied Behavioral Analysis This is a strategy based on the observation of a behavior and the events after the behavior occurs. The root cause of the behavior is then determined, afterwards, strategies are developed which would change the events before a behavior occurs, which should affect the behavior itself (Cooper et al., 2007).
Aspergsers Syndrome is a neurobiological disorder characterized by deficiencies in social and communication skills in children of normal intelligence and language development (Woodbury-Smith Volkmar, 2009).
Autism is a severe disorder of brain function marked by problems with social contact, intelligence and language, together with ritualistic or compulsive behavior and bizarre responses to the environment as diagnosed by a licensed psychiatrist or psychologist. This will include mild, moderate, severe and profound forms (American Academy of Pediatrics, 2007 American Psychiatric Association, 2006).
Behavior Modification This strategy or treatment approach replaces unwanted behaviors with desired behavior through the use of positive or negative reinforcement techniques (Gitundu, 2008).
Extinction poor behavior is not rewarded (stimulus is removed) and is therefore more likely not to occur (Gitundu, 2008).
Extinction burst is an unwanted side effect of extinction treatment generally aggressive behaviors (Gitundu, 2008).
Discreet Trials - It is a single cycle of a behavior-based instruction, which is designed to capitalize on learning. This teaching technique is used to develop self - help and social skills, communication, and cognitive skills (Bolton Mayer, 2008).
FloorTime - Caregivers, generally the parents, spend time entering the childs activities and following the childs lead (Greenspan Weider, 2006).
Maladaptive behavior is a behavior that is considered socially unacceptable or undesirable that interferes with the acquisition of desired skills or knowledge and with the performance of everyday activities (Thompson, Iwata, 2007).
Maladaptive eating related behaviors These are behaviors, which are evident when certain non-preferred foods are introduced spitting, tantrums, crying, throwing food or plate and utensils, hitting, kicking and scratching (Sallows Graupner, 2005 Schreck et al., 2006).
Pivotal Response Training is a strategy designed to increase an individuals motivation to learn new concepts while monitoring the behaviors responses to the treatment and teaches new ways to communicate with others (Koegel Koegel, 2006).
Self-Injurious behavior (SIB) This behavior can cause harm to ones body and is commonly performed through cutting, biting, scratching, hitting or scraping (Gitundu, 2008).
Tantrums are behaviors categorized by crying, screaming, hitting, kicking, non-compliance with directives (Gitundu, 2008).
Summary
The proposed study would attempt to research the question How can the maladaptive behavior, exhibited by autistic children with eating disorders, be effectively modified through behavior strategies In addition, the study will review the research hypothesis for validity There is a significant difference in the change in the amount of inappropriate eating behaviors over a 3 week period between autistic children who are treated with FloorTime (Greenspan Weider, 2006) and autistic children who are not treated with this intervention.
One in 150 children are diagnosed with Autism Spectrum Disorder (American Academy of Pediatrics, 2007). Several strategies have been developed to assist in behavior modification and further explanation of these strategies is found below. These strategies include Discreet Trials (Lovass, 2006), Applied Behavior Analysis (ABA) (Cooper et al., 2007), FloorTime (Greenspan Weider, 2006), and Pivotal Response Training (Koegel et al., 2006). A review of each strategy is found in chapter two.
About 25 of all children, in the United States, are reported to have some form of feeding disorder. These eating disorders include food refusal, food fads, overeating, failure to thrive, anorexia nervosa and pica (Bluford et al., 2007). Children with Autism, as compared with typical children, generally have food avoidance behaviors and fear of unfamiliar foods (neophobia). For the purpose of this study, important definitions were provided including Autism, maladaptive behavior, and maladaptive eating disorders.
This proposal will use a quantitative, quasi-experimental method of research and a one way within subjects ANOVA with intervention (treatment versus control) as the independent variable, and the dependent variable as frequency of inappropriate eating behaviors. It focuses on the behavior of individual participants and does not depend on averaging across subject to control the effects of random factors and therefore can be used with few or even only one participant (Bordens Abbott, 2008). The age of the population for the experiment will be between ages 5 to 8 years. All children will have been diagnosed with Autism in the mild to severe range. This study will test the validity of FloorTime (Greenspan Weider, 2006) in managing the maladaptive behaviors associated with demands placed on children to eat foods beyond their taste preferences. Behavior modification techniques are widely used to help modify inappropriate behaviors in autistic behaviors (Witwer Lecavalier, 2005).
Chapter II Review of Literature
2.1. History of Autism
In 1911, Eugen Bleuler, a Swiss psychiatrist used the term Autism to define Schizophrenia in adults (Fusar-Poli Politi, 2008 Leube, Whitney, Kirche, 2008). However, many children and adults were diagnosed as emotionally disturbed, insane or mentally retarded before 1940. Later, in 1943, Dr Leo Kanner, a professor at Johns Hopkins University redefined the word early infantile Autism. The term has remained consistent since that time. Dr Kanner made observations of 11 children between 1938 and 1943 and also studied children who had withdrawn from human contact as early as age 1 (Lyons Fitzgerald, 2007). During the same period, Hans Asperger made similar observations in Austria and discovered children who were also withdrawn from human contact, but had the ability to speak. The term Aspergers Syndrome was used to identify these individuals.
Despite these new definitions of Autism, the medical community during the period 1940 to 1960 still believed that any individual diagnosed with Autism was schizophrenic. Lyons Fitzgerald, (2007), identified individuals, initially, who were not mentally retarded, even though Autism can include this population as well. The 1960s, however, brought about change and a different understanding of the term Autism was established to include treatments and symptoms (Zager, 2005). During this period, and the lack of understanding the causes of Autism, parents and children were separated and the children placed in foster homes based on the assumption that they would recover from their condition. Fortunately, many other researchers followed with theories on best practices, found ways, which could help families, cope with children and adults with Autism. Some of these researchers included Bernard Rimland (Rimland Edelson, 2006), who wrote a book about Autism from a biological viewpoint, Bruno Bettelheim (2005), who studied Autism as a psychiatric condition, and Ole Ivar Lovaas (2007), an early developer of behavior modification in the treatment of autism.
Assessment Tools
Scores of reliable assessment tools are available for the evaluation of possible Autism in a child or adult. The list is vast, however, for the purpose of this study, a few of the key assessments will be mentioned. Childhood Autism Rating Scale, Second Edition, (Schopler, Bourgondien, Wellman, Love, 2010) is a 15-item behavior rating scale, which identifies children with autism. The scale distinguishes the difference between children who are developmentally disabled and autistic children. Gilliam Aspergers Disorder Scale (Gilliam, 2001) has several scales that include key questions, restricted pattern of behavior, cognitive patterns, early development and pragmatic skills. The scales are completed by caregivers and professionals and can be administered in a clinical setting or at home Autism Diagnostic Interview-Revised (Rutter, Le Couteur, Lord, 2007), is an investigator type interview for the parents or caregivers of adults or children with Autism. It is composed of 93 items and focuses on 3 functional areas, languagecommunication, reciprocal social interactions and restricted, repetitive, and stereotyped behaviors and interest Psychoeducational Profile-Revised (Delmolino, 2006), is a rating system composed of 131 developmental and 43 behavioral items. It is a listing of identified behaviors, which focuses on weak or undeveloped learning patterns. Bayley Scales of Infant Development (Bayley, 2005) is a useful tool that identifies Autism at an early age. It focuses on possible cognitive or motor delays and recommends various forms of intervention (Harris, Megens, Backman, Hayes, 2006). The Wechsler Intelligence Scale for Children Fourth Edition (Wechsler, 2003), incorporate psychoeducational assessment, diagnosis, placement, and planning features. Stanford-Binet Intelligence Scale, Fifth Edition (Roid, 2003), provides features in 4 important areas verbal reasoning, abstract and visual reasoning, quantitative reasoning and short-term memory. The test is designed for ages 2 years to adult age. The Gilliam Autism Rating Scale, (Gilliam, 2005), identifies Autism in children ages 3 through 22 years of age. Questions from the GARS reflect foundational information from the DSM-IV. The validity and the reliability of this instrument are rated as high.
Autism and Its Effect
To truly understand the unacceptable behaviors surrounding some autistic children, it is important to have a clearer understanding as to why a child is autistic. Autistic disorder (also called autism) is a neurological and developmental disorder that usually appears during the first three years of life (APA, 2006).
Approximately
one in 150 childrenare diagnosed with Autism Spectrum Disorder (American Academy of Pediatrics, 2007). Autism is more prevalent in boys than girls, with four times as many boys affected than girls (Simmons, 2009). The Centers for Disease Control conducted a study and found that the rate of Autism for children ages 3 to 10 years to be 3.4 per 1000 children (Zager, 2005). Making the assumption that the occurrence rate has been consistent over the last 20 years it is estimated that up to 500,000 individuals younger than age 21 have Autism (or some form of it) in the United States. This gender difference is not unique to Autism since many developmental disabilities have a greater male to female ratio.
Approximately 25 have seizures for the first time during puberty, which may be due to hormonal changes. In addition, many behavior problems can become more frequent and more severe during this period. However, others experience puberty with relative ease (Greenspan Weider, 2006).
Unfortunately, many of these individuals may not be classified as having Autism until they have attained school age or later. Behaviors associated with Autism are generally present before age 3 therefore it is important to identify these children early so they can get the appropriate intervention services (Murray, Ruble, Willis, Molloy, 2009). A child with Autism appears to live in hisher own world, shows little interest in others and displays a lack of social awareness.
Autistic children often have problems in communication, avoid eye contact, and show limited attachment to others. Autism is clustered among the family of pervasive developmental disorders (PDDs) as identified in the APA (2006). The manual states that Autism is the presence of markedly abnormal or impaired development in social interaction and communication and a markedly restricted repertoire of activity and interests. A better understanding of social interaction, communication and repertoire of activity bears further explanation and will be discussed.
In most cases, there is no specific cause for Autism in an individual. Research is ongoing in this area. Many questions have been raised as to possible causes to include vaccinations, food allergies or genetics (Williams et al., 2005). Behaviors, although most important, are secondary in that often the cause of the behavior in autistic children is still largely under research, yet there appears to be some forthcoming research by Adrian Bird (Abuhatzira, Shemer, Razin, 2009 Bird, 2008 Ghosh, Horowitz-Scherer, Nikitina, Gierasch, Woodcock, 2008), which may indicate the possibility of the reversal of the gene that causes Retts Syndrome in humans. These non-specific answers can be frustrating for parents or family members who would like some explanation to their childs dilemma (Williams et al., 2005).
Autism and Serotonin
It is understood that Autism may have many causes and that behaviors are secondary symptoms (Scarborough, Hebbeler, Spiker, Simeonsson, 2007). Many researchers agree however that serotonin is a major factor in the diagnosis of autism although it is not considered the cause of Autism (Ahley-Koch et al., 2007). Serotonin exists as a chemical in the brain known as neurotransmitters. It is also found in blood platelets. It is identified as a major factor in appetite, sensory perception, control of mood and inducing sleeps and body temperature regulation (Skaar et al., 2005). There are also indications a low level of serotonin is present in smaller populations of autistic individuals (Scarborough et al., 2007). Low levels of serotonin can also lead to compulsive behavior (Zager, 2005).
Autism and Vaccines
Research into the causes of Autism continues to puzzle the scientific community. More research is now turned toward the possibility of a biological causation (Rimland, Edelson, 2006). Although it is understood that many triggers may exist for this illness, actual determinants to Autisms onset is unclear (Goin-Kochel Myers, 2005 Scarborough et al., 2007). Vaccines could be one of the likely triggers therefore substantial research is available for review.
Researchers have documented that mercury in childrens vaccinations may contribute to early and regressive stages of Autism (Silbergeld Baker, 2008). Mercury content in vaccines in infants could exceed Environmental Protection Agency standards (Baker, 2008). A mercurial preservative from 1930s research, thimerosal, warrants full safety testing and is still used today in vaccines like Rh-immunoglobulin during gestation hepatitis B at birth and diptheria and tetanus toxoids with acellular pertussis at 2 month intervals after birth (Sugarman, 2007). Other research suggests that autoimmune lesions, the results of autoimmune illness from thimerosal based vaccines, found in some autistic children could be the cause for their poor eating habits. These lesions may exist in the gastrointestinal tract of the body. (Offit, 2007).
Social InteractionCommunication
Individuals with Autism have marked difficulty with aspects of social interaction and communication. It is unclear as this time why this difficulty exists, but more research is forthcoming (Vismara Lyons, 2007). Autistic individuals are different and how they perceive things is as different as they are. Often these individual have developed some level of social skills, but lack the desire to interact with others. This is mainly because the autistic individual does not understand the emotions of others and may have little to no interest in physical or emotion contact (Reaven, 2009). Children and adults with autism have difficulty with nonverbal and verbal communication as well. Depending on the child or adult, some individuals have difficulty making or maintaining eye contact and generally fail to comprehend facial expressions or emotions. Approximately 40 to 45 of children do not speak at all while a smaller percentage start talking between 12 to 18 months, but often lose any gains in language skill rather quickly (Densmore, 2009).
Repertoire of Activity
Autistic individuals spend much of their time preoccupied with repetitive routines. These patterns remain unchanged for number of years and often become the trademark of each individual. APA (2006) describes these patterns as preoccupation with restricted patterns of interest inflexible adherence to routines repetitive movements, preoccupation with parts of objects - Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following
Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus.
Apparently inflexible adherence to specific, nonfunctional routines or rituals
Stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex who-body movements)
Persistent preoccupation with parts of objects. (p. 75)
The preoccupation of repetitive routines can be an obsession. Body rocking, finger flapping, perseverative expressions and vocalization can be continuous and last as little as a few moments or hours at a time. It is suggested that the elimination of these repetitive routines maybe unwise, but the reduction of them should be considered. Vismara Lyons (2007) states that this behavior may be related to an obsessive-compulsive disorder and to high levels of anxiety, however repetitive behaviors cannot and should not be eliminated completely from a persons behavior repertoire. They also suggest that a reduction in the time spent performing the behavior is warranted by teaching an alternative behavior, providing a variety of sensory experience daily, diverting the persons attention to another activity, and negotiating when such actions are acceptable.
Eating Disorders Among Small Children
There is an increased concern for children who are not receiving proper nutrition because of a reluctance to eat certain foods. Refusal to eat specific foods is not uncommon among children such as the consumption of vegetables, etc. When health becomes an issue, emotional behavior is affected as well which can lead to maladaptive behavior. Czaja, Rief, and Hiblert (2009), conducted a study regarding binge eating among children 8-13. A sample population of 60 children found that children with loss of control (LOC) food consumption made a significantly higher use of dysfunctional emotion regulation strategies (p .01), especially for the regulation of anxiety (p .01). Maladaptive strategies were associated with greater depressiveness (p .001).
Behavior Strategies
There are several treatments for Autism. The severity of the condition will determine which strategy is best for the situation. These approaches include Biochemical (vitamin and food supplements introduction, medication, food allergies), Neurosensory (daily life therapy, sensorial integration, facilitated communication, auditory training, over stimulation and patterning), Psych-dynamic (psychoanalysis and psychotherapy, holding therapy) and Behavior (behavior modification with and without aversive, Discrete trials, ABA, etc) (DiGennaro, Martens, Kleinmann, 2007)
Behavior Modification
The major focus of this proposal is in the area of Behavior modification. Behavior modification techniques are used to help modify inappropriate behaviors in autistic behaviors (Shea, 2005). However, there are positive successes and negative results with this strategy. Although data and strategies currently exist, behavior modification remains a relatively new field of exploration and intervention. Many concerns are raised in the utilization of strategies that appear to confine or impede a childs freedom of choice. Consequently, ethical concerns often weigh in the balance. Conventional wisdom suggests that behavior modification represents an important component in the behavior modification of an autistic child. However, is it necessary in all cases, all the time
It is equally important to understand that children with Autism have maladaptive behavior episodes (Shea, 2005). At times this behavior may be a side effect from medication, may have a genetic basis or may be the result of external factors such as agitation, loud noises and other environmental frustrations (Iarocci et al., 2006), which may, in turn, manifest the resultant maladaptive behavior when the child is asked to perform various challenging tasks.
Most professionals in this field concur that early intervention is vital to the future success of the child. Invariably, early intervention increases the likelihood that the autistic child may function at the level of his peers (Chasson, Harris, Neely, 2007). Recently, the American Academy of Pediatrics (2007) published new Early Screening Guidelines to help identify children in need of early intervention. The guidelines provide the foundation for early intervention, but to address how the behavior should be changed and when it should be changed remain unanswered components in this puzzle. Additionally, many believe that helping professionals who treat an autistic child on a daily basis realize that behavior modifications are necessary. In short, some behaviors autistic children exhibit are socially unacceptable and often parents, caregivers, and teachers wrestle with the challenges of what to do with the child (Carcani-Rathwell et al., 2006).
Numerous individualized strategies for behavior modification exist and include token economy, behavior charts, positive reinforcement, (behavior management and inner motivation, ignoring attention-seeking behavior, contracts, desensitization, and reward tower approach). Individually or in any combination, these strategies can provide suitable behavior modification. Beyond these methods are more complex and expansive strategies, which may use some, all, or none of the individual strategies above. These complex strategies require intensive training and are generally performed by specialist or consultants. They include Discrete Trial Training or DTT, (Bolton et al., 2008), Applied Behavior Analysis (Barnill, 2008 Sallows et al., 2005), FloorTime (Greenspan Weider, 2006) and Pivotal Response Training (Koegel et al., 2006). Each of these strategies requires a brief summary of their core functions.
Discrete Trial Training (DTT)
Discrete trial training is an all-inclusive technique of behavior intervention based on the principles of Applied Behavior Analysis and is offered in schools and home based programs. It is a single cycle of a behavior-based instruction, which is designed to capitalize on learning. This teaching technique is used to develop self - help and social skills, communication, and cognitive skills (Bolton et al., 2008). It involves breaking skills down into smaller manageable components and teaching those components individually. The type of task will differ in its level of complexity. One task is often the foundation of another such as teaching a learner to sit quietly for a short duration without tantrums (Isaksen Holth, 2009). Sitting is a prerequisite for other tasks such as sitting behind a computer to perform yet another task. Therefore this strategy is designed to increase the learners opportunity to present adaptive behaviors. It is not designed to reduce maladaptive behaviors.
A particular trial may be repeated several times in succession, several times a day, over several days until the skill is mastered (Bolton et al., 2008). Modest information is provided to the learner and the learners reaction is consequently reinforced or not reinforced. There are four parts discriminative stimulus (the instruction), the prompting stimulus (instructor prompting), response (targeted skill or behavior), reinforcing stimulus (motivation reward) and inter-trial interval (pause between trials) (Reagon Higbee, 2009). Each trial has three parts Antecedent or instruction, Behavior of Student and Consequence (reinforcement). Data is collected and analyzed to identify patterns in responding including the increases or decreases of targeted behaviors (Isaksen et al., 2009).
Applied Behavior Analysis (ABA)
It has been long recognized that a small population of autistic individuals display maladaptive behavior. As a result this strategy was developed to counter these behaviors.
Applied behavior analysis is the process of systematically applying interventions based upon the principles of learning theory to improve socially significant behaviors to a meaningful degree, and to demonstrate that the interventions employed are responsible for the improvement in behavior (Reagon et al., 2009). A basic premise of ABA is to observe the behavior and the events after the behavior occurs. Then determine what causes the behavior, change the events before a behavior occurs, which should affect the behavior itself.
Widely considered as a science of human behavior, ABA was created by behavior psychologists and was designed as an instructional strategy for individuals diagnosed with Autism and mental retardation (Barnill, 2008 Sallows et al., 2005). It is the implementation, creation and assessment external modifications, which in turn produce major social changes in the behavior of the patient (Lanovaz, Fletcher, Rapp, 2009). This process uses functional analysis, measurement and direct examination of the reasons for behavior, and the root causes of the behavior.
ABA is different from most psychological strategies. Most psychological strategies focus on a social learning paradigm involving beliefs, expectations, traits, and abstractions, however behavior analysis does not hypothesize psychological root cause for behavior. The actual behavior is the focal point of interest. Behavior patterns are interpreted in terms of their frequency, variation and how the behavior relates to the environment. Genetics, brain chemistry, physiology, and related factors play a role in understanding behavior. Behavior analysis assumes that certain functional relationships between behavior and the environment are true for individuals or species because of genetic endowment (Vismara Lyons, 2007).
This strategys focal point is on rewarding positive behavior and rejecting negative behavior through control measures. It uses stimulus and cost response based on observation and the development of a functional assessment all of which are designed to produce behavior change. Foundationally, ABA is based on the view that behavior is a product of past and current experiences coupled with other variables such as heredity. (Lang, OReilly, Lancioni, Rispoli, 2009). Good behaviors warrant rewards. Bad behaviors are not rewarded. This process has several behavior principles shaping, chaining and successive approximation (Wilder, Harris, Reagan, Rasey, 2007). It is often challenging for autistic children to learn new and often complex behaviors. ABA seeks to reduce complex tasks to simpler tasks, making it easier for the child to learn. The success of ABA as with any intervention program - relies on the consistency of application in residential, vocational and therapeutic environments.
FloorTime
Dr. Stanley Greenspan (Greenspan Weider, 2006) developed the FloorTime strategy. This strategy can be applied as an intervention program for children with Autism. The main focus of the developmental model is on reestablishing the disordered developmental sequence by following the childs lead and internal motivation in unstructured interactions, including play. Therapists and practitioners analyze the interactive patterns of a child and family and train the caregivers in applicable strategies in social and emotional interactions (Greenspan Weider, 2006).
Pivotal Response Training
Pivotal Response Training (PRT) is a behavior intervention strategy, which uses a naturalistic treatment approach. It was developed by Drs Robert and Lynn Koegel at the University of California at Santa Barbara and is based on the principles of Applied Behavior Analysis (ABA). The purpose of the strategy is to increase an individuals motivation to learn new concepts while monitoring the behaviors responses to the treatment and teach new ways to communicate with others (Camp, Iwata, Hammond Bloom, 2009). The developers identified two behaviors (motivation and responsivity) that appear to be the foundational behaviors for a broad range of behaviors for children and adults diagnosed with Autism. The premise is that if positive changes are made to these core behaviors, it will affect all other behaviors (Koegel, et al, 2006). These core behaviors are considered pivotal to the process of behavior modification.
Pivotal behavior is defined as areas that are central to wide areas of functioning such that improvements will occur across a large number of behaviors. Intervening in a pivotal area produces large collateral improvements in other areas (Koegel et al., 2006).
PRT works to increase motivation by including components such as child choice turn taking, reinforcing attempts and interspersing maintenance tasks. PRT has been used to target language skills, play skills and social behaviors in children with autism (Koegel et al., 2006). Major components of PRT include
Choice (shared control to increase motivation). 12 point
Clear and uninterrupted instructions or opportunities (make sure child is attending).
Reinforcement of approximationsattempts.
Reinforcement has a specific relationship to the desired behavior natural reinforcement (ball gets ball, not praise. Child chooses object for instruction and that object is used. This is done to increase motivation). p. 149
A key component to this strategy is the reinforcing of effort through reward systems. In Applied Behavior Analysis the individual is required to perform a specified task. Individual failures that do not accomplish an assigned task are not granted a reward. If the task is performed properly, the rewards are granted. In PRT if the individual attempts to complete the task, in any form, the behavior is reinforced through rewards.
TEACCH
Treatment and Education of Autistic and related Communication handicapped Children (TEACCH) is a program designed to change the way a child views his environment. It emphasizes structure, manipulation of antecedents and consistency. Additionally the strategy emphasizes assisting the child in developing social and communicative behaviors (Mesibov, Browder, Kirkland, 2002). The program was developed to respond to maladaptive challenges of special need children and families.
TEACCH is not a singular method but an adaptive program of several approaches, which, depending on the childs need, uses techniques best suited for the child. The programs main goal is the help autistic children achieve a level of autonomy as their progress to adulthood (Mesibov, Shea, Scholar, 2005). This includes helping them understand the world that surround them, acquiring communication skills that will enable them to relate to other people and giving them as much as possible the necessary competence to be able to make choices concerning their own lives (Van Bourgondien, Reichle, Scholar, 2003).
An important aspect of the program is to improve the communication skills of the child through the use of various educational programs. Since the program is adaptive, the educational programs are tailored to the childs specific needs (through the use of a detailed assessment called PEP, Psycho Educational Profile) based on the level of maturity (Mesibov et al., 2002). The focus is on the childs potential and less focused on the childs deficiencies.
The program is not designed to change or modify behavior like other behavior modification techniques, but used to encourage and enhance the learning experience of the child. Maladaptive behavior does occur on occasion, but TEACCH does not treat the behavior direct (Mesibov et al., 2005). The approach focuses on the root cause of the behavior (i.e., boredom, anxiety, difficulty tasks or physical pain) then adapts accordingly. Changes to the environment, as an example may reduce the anxiety or boredom, modification of the task may ease the challenge of difficulty the child experiences and addressing the cause of the physical pain through the use medication or a rest period, could cause cessation of the problem (Van Bourgondien et al., 2003). Direct behavior modification is used during the periods when the above strategies fail and the child or others involved in the instruction of the child are endangered.
Gluten Free, Casein Free Diet (GFCF)
In a search to find suitable strategies that will help their child, parents often turn to alternative methods to cope with behavioral concerns. Dietary and nutritional interventions, on occasion, help some children with autism spectrum disorder through the removal of gluten (protein found in wheat, rye, oats and barley) and casein (protein found in dairy products) (Marcason, 2009). Theoretically, proteins are absorbed differently in autistic children resulting in atypical behaviors and physical challenges (Christison Ivany, 2006).
The hypothesis is not based on an allergic response. Neither the hypothesis nor the effectiveness of this dietary intervention has been demonstrated in scientific studies to date (Peregrin, 2007). Research is ongoing, however, some many families report when of gluten and casein were eliminated from the childs diet, substantial improvements were recorded in bowel habits, sleep, activity, and habitual behaviors.
A trial of dietary restriction requires attention to basic nutritional guidelines. Dairy products are the most common source of calcium and vitamin D in young children in the U.S (Ledford Gast, 2006). Many young children depend on dairy products for a balanced protein intake (Christison Ivany, 2006). Families are challenged to find suitable alternation sources of nutrients for their children. Vitamin and supplements are helpful but could pose positive and negative side effects (Carton, 2005).
Occupational Therapy
Occupational Therapy has shown to improve the quality of life of autistic persons (Hodgetts Hodgetts, 2007). Areas such as coping skills, fine motor skills, play skills, self help skills and socialization have shown marked improvement through the use of occupational therapy (Phelan, Steinke, Mandich, 2009). Autistic individuals are assisted at home and within a school setting with such activities as dressing, feeding, toilet training, grooming, social skills, fine motor and visual skills at assist in writing and scissor use, gross motor coordination (Solomon, Hessl, Chiu, Hagerman, Hendren, 2007). Occupational therapy is usually part of a collaborative effort of medical and educational professionals, as well as parents and other family members (Levy, Mandel, Schultz, 2009).
Picture Exchange Communication System (PECS)
PECS is an alternative communication technique, which utilizes picture cards and is designed for individuals who have little to no verbal ability. Individuals use these cards to express a desire or feeling (Spencer, Petersen, Gillam, 2008). The pictures can be purchased commercially or created at home using books, newspapers or magazines. This alternative communication has proven to be effective especially among the autism population and has shown to improve independent communication skills (Spencer et. al., 2008). The training is conducted in two stages. In stage one, the trainer provides an image of a preference item (food or a toy) (Howlin, Gordon, Pasco, Wade, Charman, 2007). If the individual responses positively to the image, a foodtoy card(s) are created. The trainer then works with the individual to help himher discover that giving the card to the trainer will produce the item of choice. The training is conducted while sitting or standing next to the individual. In stage two, the trainer moves farther away from the individual when displaying the pictures, so that the individual must approach the trainer with the card to get the item of desire (Spencer et al., 2008).
As the individual gains a better understanding of the process, other stages are introduced with the intention of further expanding the vocabulary of the individual. In the later stages, the individual is given two or more pictures and must decide without of the cards will be used for the request (Spencer et al., 2008). The individual may also be encouraged to use simple phrases like I want or saying the color of the item red. For some children this process may take weeks or months. The use of this process assists in reducing maladaptive behavior associated with communication challenges (Howlin, et al., 2007).
Relationship Development Intervention (RDI)
Relationship Development Intervention (RDI) is based on the research of psychologist Steven Gutstein. The program is a parent- focus strategy that focuses on the foundational problems of creating friendships, expressing affection and being able to share experiences with others. Though his research, Dr Gutstein found that individuals on the autism spectrum lacked the necessary ability to cope with real life situations (Gutstein Whitney, 2002).
He calls these abilities dynamic intelligence and labels them as 1) Emotional Referencing - The ability to use an emotional feedback system to learn from the subjective experiences of others 2) Social Coordination - The ability to observe and continually regulate ones behavior in order to participate in spontaneous relationships involving collaboration and exchange of emotions 3) Declarative Language - Using language and non-verbal communication to express curiosity, invite others to interact, share perceptions and feelings and coordinate your actions with other 4) Flexible thinking - The ability to rapidly adapt, change strategies and alter plans based upon changing circumstance 5) Relational Information Processing - The ability to obtain meaning based upon the larger context and solving problems that have no right-and-wrong solution and 6) Foresight and Hindsight - The ability to reflect on past experiences and anticipate potential future scenarios in a productive manner (Gutstein Sheely, 2002).
The SCERTS Model
The SCERTS Model is a team-based, multidisciplinary model for enhancing abilities in Social Communication and Emotional Regulation, and implementing Transactional Supports for children and older individuals with autism spectrum disorders (ASD) and their families (Prizant, Wetherby, Rubin, Laurent, 2003). SCERTS is not a stand-alone approach, because it provides a foundation in which practices and strategies from other approaches can be used. The SCERTS model is a comprehensive but flexible approach, which can be used with individuals of different ages and developmental abilities. One of the main emphases of the model is child-initiated communication in normal or semi-structured activities for purposes such as making requests, extending a greeting, expressing emotions andor protestingrefusing. Objectives for the child are appropriate for their stage in development and often target both verbal and non-verbal forms of communication (Walworth, Register, Engel, 2009).
Each part of the SCERT has an individual purpose. The Social Communication program involves developing unstructured, practical communication and secure, trusting relationships with children and adults. Emotional Regulation enhances the capability to sustain an emotional state that is available for learning and interacting (Prizant et al., 2003). Transactional support includes supporting children, their families, and professionals to maximize learning, positive relationships and successful social experiences across home, school and community settings (Walworth, 2007).
Sensory Integration Therapy
Sensory Integration is the process through which the brain organizes and interprets external stimuli such as movement, touch, smell, sight and sound (Hyatt, Stephenson, Carter, 2009). It is common for autistic children to show evidence of Sensory Integration Dysfunction (SID), which makes it difficult for them to process information through the senses (Hess, Morrier, Heflin, Ivey, 2008). Children diagnosed with SID may have mild, moderate or severe deficits in increased (hypersensitivity) or decreased (hyposensitivity) to touch, sound, movement, etc (Smith Bennetto, 2007).
The Sensory Integration Therapy process enhances the nervous systems ability to process sensory input in a more usual way. Through integration the brain pulls together sensory messages and forms coherent information upon which to act (Hess, Morrier, Heflin, Ivey, 2008). The SIT process uses neurosensory and neuromotor applications designed to improve the brains ability to repair any previous damaged sensory areas (Hess et al., 2008). If the process is successful, SIT can improve such area as attention, listening, comprehension, coordination and impulsivity control in some children (Smith Bennetto, 2007). The therapy (generally provided by licensed occupational or physical therapist) frequently requires activities that consist of total body movements utilizing different types of equipment (Reichow, Barton, Sewell, Good, Wolery, 2010).
Speech Therapy
The integration of Speech Therapy as part a well-managed behavior program designed to help autistic individuals is important to their overall development. Any attempt at therapy, however, must begin with an individual assessment of the childs language abilities by a trained speech and language pathologist (Willis, 2009). In most cases autistic individuals have difficulty in formulating and speaking in clear concise sentences. This is of course, dependent on the degree of intelligence and social development of the individual. Some autistic individuals do not speak at all, or speak with just one or two words at a time while others may talk at length about a topic of interest (Schlosser Wendt, 2008). Still others may speak with a high pitched or low monotone voice. Those individuals who do have little to no difficulty speaking or using sentences have some difficulty using language effectively (i.e., knowing what to say, when to say it or how to say it). Many who speak often say things that have no content or information. Others repeat verbatim what they have heard or repeat irrelevant scripts they have memorized (Reichle, Dropik, Alden-Anderson, Haley, 2008).
There are two important skills for language development that most autistic individuals lack. They are joint attention and social initiation (Ganz, Kaylor, Bourgeois, Hadden, 2008). Joint attention utilizes an eye gaze and referential gestures such as pointing, showing and giving. Children with autism generally lack the ability to ask meaningful questions and fail to use language as a means of social initiation (Willis, 2009). Clearly, no one treatment is successful in improving the communication of all autistic individuals, but the best treatments should begin early during the preschool years. Periodic evaluations must be made to find the best approaches and to reestablish goals for the individual(s) as they age (Smith Bennetto, 2007).
Verbal Behavior Intervention
During the late 1950s and early 60s Dr. Ivar Lovaas developed the Applied Behavioral Analysis (ABA) principles (the use of behavior analytic methods and research findings to change socially important behaviors in meaningful ways). During the same time period, Dr. B. F. Skinner published Verbal Behavior, which detailed a functional analysis of language (Jones, Feeley, Takacs, 2007.) He explained that language could be grouped into a set of units, with each operant serving a different function (Luyster, Kadlec, Carter, Tager-Flusberg, 2008). Verbal Behavior Intervention is similar in many ways to the principles of Applied Behavioral Analysis, but the overall concepts differ.
The primary verbal operants of Verbal Behavior are termed mands (to request or obtain what is wanted), tacts (labeling of an item based on visual cues), and intraverbals (verbal responses in conversational language) (Jones Schwartz, 2009 Reichow Sabornie, 2009). VB attempts to capture a childs motivation to develop a connection between the value of a word and the word itself (Ozdemir, 2008). Many therapists are now using techniques of VB to bridge some of the gaps seen in ABA (Kelley, Shillingsburg, Castro, Addison, LaRue, 2007).
Maladaptive Behavior
Children with Autism who display maladaptive behavior draw attention to themselves or something in the environment. Avoiding a task is generally the root cause of this behavior. Currently, those with Autism Spectrum Disorder (ASD) are categorized into five types of maladaptive behaviors. These include stereotypical, ritualistic, self-injurious, tantrum, and aggressive behaviors. Stereotypical behavior, is defined as repetitive movement of the body or objects (Li, 2009), and can involve any of the sensory pathways. Stereotypical behaviors include hand flapping, tapping ears, scratching, rocking, mouthing, sniffing, and other such behaviors. Stereotypical behavior appear to stimulate the senses of autistic children while perhaps causing feelings of internal pleasure, due to a simultaneous release of beta-endorphins in the brain. It serves to calm the individual, but focuses his or her attention inwardly and away from attention to learning or completing a task (Waters, Lerman, Hovanetz, 2009).
Often maladaptive behavior is an attempt to communicate protest against performing a task, or an indication of some discomfort or stress. Most stressors are internal, sensory, or external. Internal stressors are within the body or mind, which include ideas and memory as well as physiological difficulty or discomfort. Zwaigenbaum, Bryson, Lord, Rogers (2009), reports evidence of internal differences in the use and structure of the limbic system, cerebellum, and frontal cortex in this population. These differences affect how the individual perceives and responds to the world, including what is pleasurable or painful to that person.
Zwaigenbaum (et al., 2009) also found that in one form of maladaptive behavior (self-injurious) 26 was caused by misused positive social attention. For example, if a child found that head banging was a means of gaining social attention from a desirable person, he or she may bang his or her head every time he or she would like attention. Clearly, escaping a demand is a strong motivator for maladaptive behavior. Families For Early Autism Treatment, Inc found that 38 of self-injurious behavior was used as a way to escape demands. People with Autism may not have an appropriate way to say NO, or request a break, so they obtain a break from demands any effective way available to them. Their difficulty lies in their inability to easily learn skills that give typical children a sense of control over their environment (Waters et al., 2009).
Different possible outcomes to behavior modification
Obviously, the goal of behavior modification is to achieve balanced responses to introduced tasks. However, negative implications can develop with the use of this strategy. With the introduction of new contingencies that surround the maladaptive behavior, the child may become frustrated and upset, particularly since the previous pattern of response functioned less effectively than in the past. It is likely that the child will test the limits and will experience extinction bursts where behaviors get worse before it gets better or which may re-emerge under novel or challenging circumstances.
Although defined above, the terms extinction, extinction burst or resistance to extinction, merit further explanation (Camp et al., 2009 Thompson et al., 2007).
Jolivette, Gallagher, Morrier Lambert (2008) agree with the seminal work of Adelman Maatsch, The word (extinction) carries connotations of destruction and loss. We might expect old habits and memories to become extinct, irrecoverable, and irreplaceable. However, that is not what happens in the process of extinguishing an operant response. For this reason, it is best to consider the term acquisition of extinction, (which is) a process of continued learning. At issue is whether it is the learning to inhibit a response done earlier, the learning of a new response opposite to or incompatible with that performed earlier, or the learning that the earlier response is simply no longer effective. Additional challenges exist concerning behavior modification, which could inhibit successful treatment. However, once the behavior is determined and its function analyzed, the next step is to identify alternate, acceptable behaviors with which you wish to replace the inappropriate ones.
Consistency is important in the modification of inappropriate behaviors. Consequently, there exists a twofold purpose to locate alternatives that address inappropriate behaviors in the autistic child. First, it is to create socially acceptable behaviors, which can, in turn, become the normal behavior of the child. Secondly, behaviors that meet the needs that the original behavior met must be identified. The researcher concede that the location of alternative behaviors may prove challenging. For instance, the child may not possess the requisite skills necessary to perform the new behavior (Camp et al., 2009). In the example above, if the child has problems with expressive language, he or she may not be able to say the word. This could easily lead to additional frustrations that were present before the new behavior began, and that may eventually backfire on the parentcaregiver. If the desired behavior is not something the child already has in hisher repertoire, then it must first be taught and then methodically integrated into the behavior patterns of the child (Petscher Bailey, 2006).
To identify behaviors that require change, and to teach acceptable replacement behaviors represents a time consuming process for both the parentcaregiver and the child. If used, however, this process has proven successful for several populations, i.e., autistic children, mental health professionals, parents, etc., individuals and in the educational setting. The keyword to effectively working with this process is consistency. By consistent adherence to a pattern of positive reinforcement, behaviors can be taught that will benefit the child in hisher efforts to meet social expectations.
Behavior Extinction
Clearly, the goal of behavior modification is to therefore, achieve balanced responses to introduced tasks. However, negative implications can develop with the use of this strategy. With the introduction of new contingencies that surround the maladaptive behavior, the child may become frustrated and upset, particularly since the previous pattern of response functioned less effectively than in the past. It is likely that the child will test the limits and will experience extinction bursts where behaviors get worse before it gets better or which may re-emerge under novel or challenging circumstances (Thompson et al., 2007).
Consistency is important as well in the modification of inappropriate behaviors. Consequently, there exists a twofold purpose to locate alternatives that address inappropriate behaviors in the autistic child. First, it is to create socially acceptable behaviors, which can, in turn, become the normal behavior of the child. Secondly, behaviors that meet the needs that the original behavior met must be identified.
Eating Disorders
Eating disorders are identified, as a condition by which there is an acute interruption of proper eating habits. The APA (2006) categorizes Anorexia Nervosa (refusal to maintain a minimally normal body weight), and Bulimia Nervosa (repeated episodes of binge eating followed by inappropriate self-induced vomiting), as major disorders. These eating disorders consist of harmful feelings about body mass, food and consumption habits that interrupt usual body function and every day activities. On average eating disorders affect one or two of every 100 students (Kalyva, 2009).
The image children perceive about themselves can be formed in household where a parent may have concerns about body image. Anschulz, Kanters, Strien, Vermulst, Engles (2009) study found that children ages 7-10 are often dissatisfied with their own body weight when influenced indirectly by maternal weight concerns. The researchers collected data from 501 children and it was determined that gender factors did not make a difference in the childs perception. This perception resulted in the childs restraint from standard food consumption. Blissett, Meyer, Farrow, Bryant-Waugh, and Nicholls, (2005) and Farrow Blissett (2009) have similar findings in their study presenting evidence that maternal attitude toward body image during pre natal and pro natal care can influence a childs feeding habits which could lead to difficulties later.
Denoma, Lewinsohn, Gau, Joiners (2005) sample of 36-month-old children (N93) suggests that parental perception of their childrens body image can influence the childs reaction to food. The researchers established a four-factor solution, which identified a) pickiness, b) food refusal, c) struggle for control, and d) positive parental behavior as common maladaptive behaviors in children with eating disorders.
Outside influences can affect a childs perception of food. Holub, Musher-Eizenman, Persson, and Edwards-Leeper (2005), study presented the case for children (mean age 5.2 years) who did not fully understand the word diet or weight loss, but did on occasion use restraint type behaviors. Girls, more often than boys and heavy children practiced food restraint and yet in the study by Strien Oosterveld (2008), 7 to 12 year old children were measured for unhealthy life style (382 boys and 387 girls) and for body dissatisfaction and parental feeding styles (252 boys and 263 girls). The researchers established that emotional eating indicates the majority of young children show an unacceptable reaction to emotional stressors (loss of appetite when feeling lonely, depressed or afraid).
Conversely, Maldonald-Duran et al., (2008), conducted a clinical study of infants in the first 2 years of life and the interactions of the child to the mother. They found that poor eating habits may not be associated with parental influence or poor feeding techniques, but with the age of the very young child (infant regulating states and sucking), older infant (aversion to feeding difficulties in chewing and children with unique feeding problems (pica).
Autistic Children and Comparison with Control Groups
There exists limited research regarding the feeding behavior and nutritional of children with autism (Lukens Linscheid, 2007) although numerous documents discuss the significance of the associated feeding problems of the disorder. As previously noted in the introduction section of this study, children with Autism, as compared with typically children, generally have food avoidance behaviors and fear of unfamiliar foods (neophobia). These children often consume what they desire (maintaining control over the feeding) and reject what they do not desire (Martins et al., 2008).
Children with autism may have sensory sensitivities, which can affect their eating habits (Herndon, DiGuiseppi, Johnson, Leiferman, Reynolds, 2009) and may reject foods on based on the texture versus the taste. A study was conducted which examined the feeding habits of 30 children diagnosed with Autism or Pervasive Developmental Disorder-Not Otherwise Specified. The study reports that about 50 of the children had significantly low levels of food acceptance. No control group was used and the study did not consider such factors of time of day, types of foods, or level of hunger (Martins et al., 2008). When strange food textures are introduced, behaviors can occur (Blissett et al., 2005).
High sugar diets and poor nutrition are major contributors to hyperactivity andor irritability leading to other such maladaptive behaviors as tantrums, throwing foods across the room, spitting, or physical aggression. Poor nutrition leads to improper cognitive development, less than optimal physical weight and vitamin deficiency (Wallace, 2009). When demands are introduced designed to encourage the child to consume a food different from the preferred preference, maladaptive behaviors are manifested (Thompson et al., 2007). Several studies show that children with autism often resist changes in diet and protest if their routine is changed (Kerwin, Eicher, Gelsinger, 2005). Aggressive behavior is noted as no more than a form of communication, yet parents express concern of such issues as weight loss and mood changes in their children (Buckley, Strunck, Newchok, 2005).
Schreck et al., (2006) earlier noted that children with poor feeding habits often present disorderly behaviors during the feeding cycles that can disrupt food consumption, which includes, crying, screaming, spitting food out of mouth or self injurious behaviors.
Herndon et al., (2009) conducted a comparative study that reported the nutritional consumption of autistic children (n 46), and the control group (non-autistic children) (n31), over a 3-day period. On average autistic children selected foods that had more vitamin B6 and E and non-dairy protein servings and less calcium (p . 05). The study further concludes that repetitive behavior may contribute to which foods the autistic child may select and that large numbers of children in both the control group and autistic group did not meet the daily nutritional requirement of food intake of calcium, iron, fiber and vitamins E and D.
Further studies show that children with autism and typical children have similar feeding habits and picky preferences with only a slight increase in food rejection by autistic children (Martins et al., 2008). William et al., (2005) validated these findings in a study of 178 children (children with autism, children with special needs without autism and children without special needs). Schreck et al., (2006) later employed the use of a control group (n298) (with Gilliam Autism Rating Scale (GARS) (Kaplan Saccuzzo, 2005). Children that scored less than 80 indicated a low probability of autism). Autistic children, (n138)(with GARS scores greater than 80 indicated a high probability of autism), displayed both food restriction and food refusal. These children only wanted to use certain types of eating utensils and their food had to be prepared the same way each time. When compared to typical children in this age group, autistic children often would not accept certain foods in all categories of presentation (proteins, starches, dairy, vegetables and fruit). These same children were also more accepting of foods with very low to no texture (Schreck, et al).
More studies are being developed in the continued review of this evidence regarding Autism. Kayva, (2009) conducted research with 112 adolescent girls with 56 having Asperger syndrome and 56 without the disorder. The results of the findings report that the Aspergers group had a higher risk of eating problems because of their ritualistic behavior toward food consumption.
Addressing these feeding concerns at the earliest stages is important to parents and clinicians alike. Strategies include, nutritional supplements and behavior modification. Feeding concerns can lead to nutrition and health deficiencies that could endanger the well being of the child (Martins et al., 2008). Research has shown that feeding issues of children with autism run a higher risk for nutritionally related medical problems (Wallace, 2009). Lukens Linscheid, (2007), conducted research with 68 children with Autism (56 males, 12 females), on the topic of food refusal. Their data provided stronger evidence of the marked difference in food preference and attitude of autistic children versus that of typical children, which was in direct conflict with the findings of Schreck et al., (2006).
Lukens and Linscheid found that when children are measured by the Behavior Pediatric Feeding Assessment Scale (BPFAS) a 35 item standardized questionnaire indicates how often a child engages in a particular eating behavior using a 5-point Likert scale. Autistic children often rated higher on average than non-autistic children in feeding behaviors (typical child, mean is 65.22 with SD of 13.71) (Autistic child, mean is 83.30 with SD 16.51)
Summary
Refusal of certain food groups is not uncommon among children however, with an autistic child this refusal could lead to health issues such as malnutrition. Food refusal can also affect the emotional stability of the child therefore causing behavior maladaptive (Czaja et al., 2009).
Autism is defined and explained as a disorder which is a neurological and developmental disorder that appears early in the life of a child generally within the first three years (APA, 2006). On average it affects 1 in 150 children and is most prevalent in young boys (American Academy of Pediatrics, 2007). Behaviors associated with Autism are present prior to age 3 and it is recommended that appropriate intervention services be identified which could assist families as needed (Rowlandson Smith, 2009). Although there is no clear cause for Autism, researchers have identified possible causes of the disorder, which include vaccinations, food allergies or genetics. Abnormal levels of serotonin in the brain have been linked to individuals diagnosed with Autism although its link to these levels is unclear (Williams et al., 2005).
Autisms origins and what causes the disorder largely remains a mystery. Dr Leo Kanner classified the disorder in its present definition in the 1940s. Through the years many researchers (Woodbury-Smith et al., 2009) supported Dr Kanners hypothesis and developed strategies, which could aid families in coping with the disorder. Improvements in education, treatment, behavior management, biological and medical research and communication soon followed.
Within the first 3 years in the life of an autistic child, a reduction in social interaction and communication skills is apparent (Vismara et al., 2007). They may develop some level of social interaction and communication skills, but the desire to interact with others is present (Miller et al., 2005). Additionally, autistic children develop a repertoire of activities that remain unchanged through the years. The APA (2006) describes these patterns as preoccupation with restricted patterns of interest, inflexible adherence to routines, and repetitive movements preoccupation with parts of objects. These repetitive routines include body rocking, finger flapping, perseverative expresses and vocalization.
Several behavior approaches are identified in chapter two, depending on the severity of maladaptive behavior of the autistic child that could help in the behavior management. Some of these approaches include biochemical, neurosensory, psychodynamics and behavior (DiGennaro et al., 2007). The Behavior modification (Czaja et al., 2009) technique was developed and designed to alter maladaptive behavior in autistic children and adults. These techniques include Discrete Trial (Lovaas, 2006), Applied Behavior Analysis (Cooper et al., 2007), FloorTime (Greenspan Weider, 2006), and Pivotal Response (Koegel et al., 2006). As a result of a behavior modification strategy, extinction burst are considered common. With the introduction of new contingencies, the child will be frustrated and test the limits of the new strategy. It is expected that there will be an increased in unwanted behaviors (Lopez, Lincoln, Ozonoff, Lai, 2005).
Children with autism may have sensory sensitivities concerns, which could affect their overall feeding habits (Herndon, DiGuiseppi, Johnson, Leiferman, Reynolds, 2009). As a result, these children often reject foods on based on the texture rather than taste. A comparison was made between autistic versus typical children with similar feeding habits and found that the difference overall is minor (Martins et al., 2008), however, it is important to address feeding concerns as earlier as possible as well while employing strategies of nutritional supplements and behavior modification (Martins et al., 2008).
Chapter III Research Method
Children with Autism, as compared with typical children, generally have food avoidance behaviors and fear of unfamiliar foods (neophobia). These children often consume what they desire (maintaining control over the feeding) and reject what they do not desire (Martins et al., 2008). These children maybe affected by the texture of the food (soft, hard, smooth,) or the smell of the food (sweet, spicy, bland, robust).
Restatement of Research Questions
Behavior modification techniques often aim at eliminating inappropriate behaviors in general and can reasonably be assumed to have potential benefit in the treatment of inappropriate eating related behaviors. The proposed study will evaluate the effectiveness of one particular behavior modification technique, FloorTime (Greenspan Weider, 2006), on the inappropriate eating related behaviors of autistic children. The proposed study will research the question and hypotheses as follows
Question To what extent does the FloorTime technique significantly decrease the frequency of inappropriate eating behaviors among a select group of autistic children ranging in age from 5 to 8 years
Ho There is no significant decrease in inappropriate eating behaviors over a 3- week period for the select group of autistic children ages 5 to 8 years, treated with the FloorTime technique when compared to autistic children not treated with this intervention.
Ha There is significant decrease in inappropriate eating behaviors over a 3- week period for the select group of autistic children ages 5 to 8 years, treated with the FloorTime technique when compared to autistic children not treated with this intervention.
Research Methods and Design
Research methodology plays a crucial role in shaping the course of action for the research study. A research carried out in an objective manner not only helps in the researcher in arriving at a contemporary conclusion, but it also provides substantial information for a benchmark on the particular subject, which in turn proves helpful for future research activities. Method of gathering and analyzing the data forms the philosophical part of the research activity. Deductive and inductive types of reasoning assist us in data collection and subsequent analysis. For this particular subject, a comprehensive literature review with the help of journals and research findings in the recent past will prove to be a good starting point. While on the one hand, this will help us in understanding the subject, a comparison of existing and desired tools and techniques also helps in generating a debate. Besides carrying out a literature review, the study will also gather data by observing the general habits, preferences and behavior of autistic children. Efforts will also be made to interview some people involved in looking after such children.
The proposed study will be conducted through the use of a quasi-experimental method of research and a one way within subjects ANOVA with intervention (treatment versus control) as the independent variable, and the dependent variable as frequency of inappropriate eating behaviors. The participants used cannot be randomly assigned from among all autistic children, but will be assigned from the available residential locations of a home based treatment program designed to treating autistic children. A baseline will be taken of specific eating related inappropriate behaviors among the participants.
Quantitative research constructs include The maladaptive behavior of autistic children and relevance of congruent behavior modification strategies in a treatment modality, which will address the gradations of behavior modification, the degree of efficacy of techniques used and challenges associated with these strategies how can the maladaptive behavior, exhibited by the vast majority of autistic children, be effectively modified through behavior strategies and autistic children with maladaptive behavior patterns may benefit from established behavior modification strategies.
Quasi - Experimental Method
The proposed study will be conducted through the use of a quasi- experimental design (Bordens Abbott, 2007). This mode of research will be most effective because it allows for the maximum control over the participants with the expectation of providing valid data. Data initially, will be collected from the primary caregiver of the participants. This information will be logged on the Behavioral Pediatrics Feeding Assessment Scale (BPFAS)(Appendix A) (Linscheid, 2006). Data will be collected over a period of 5 days and 10 hours of observation (2 hours a day) utilizing the Antecedent, Behavior and Consequences (ABC) form (Appendix B) (Carter Horner, 2007) and the BPFAS. The observation will include family dynamics, maladaptive behavior and caregiver reactiontreatment of the behavior. Introduction of the treatment(s) will be made after the observation period has concluded. After the introduction of the treatment more observations will be made at predetermined intervals and additional data will be collected. An evaluation of the collected data will be contrasted and compared (among all strategies selected for this study) with all collected observation data before and after the treatment.
Participants
Target population for this trial is three to five autistic children of 5 to 8 years of age with mild to severe behavior problems. An existing diagnosis of Autism as substantiated by a licensed practitioner (psychiatristpsychologist) and maladaptive behavior as observed by the caregiver (parents) are the qualifiers for this trial. Families that meet the criteria for children with maladaptive behaviors will be given the procedures for the trial. Informed consent forms will be used prior to the study explaining the purpose of the experiment, outlining the hypothesis and precautions taken and whether the experiment has been approved for ethical considerations (Bordens et al., 2007). Local advertisement soliciting participants will not be conducted and is limited to home-based counseling populations currently in place. Families outside of the home-based counseling population who desire to participate in this trial will benefit from the results of the study.
Each child will be qualified or disqualified for acceptance to this study (based on recent medical history and diagnosis), as to whether they are both physically and mentally competent for eligibility in this trial. Preexisting conditions unrelated to autism or maladaptive behavior (such as poor, gross or fine motor skills, non ambulatory, mildmoderate mental retardation) is not reasons for exclusion. Severe to profound mental retardation cases (who may have a comorbid diagnosis of Autism) as determined by a recent diagnosis and children diagnosed with Aspergers Syndrome (within 5 years by a licensed professional clinician) will be excluded from the trial.
MaterialsInstruments
This proposed study will employ the use of FloorTime (Greenspan Weider, 2006) with autistic children who are non verbal, who have difficulty sitting at the family dinner table and who have a self-limiting diet of very few foods (one to two types of food which may not have any nutritional value) (Martins et al., 2008 Williams Foxx, 2007). Despite the maladaptive behavior of the participant, there is an inherent danger to the physiology and cognitive functions of the child. A self-limiting diet can lead to malnourishment and other physicalpsychological problems as well (Williams et al., 2007). This study will test the validity of FloorTime five-step process (observe, approach, follow the childs lead, extend and expand play and let the child close the circle of communication) (Greenspan Weider, 2006) in managing the maladaptive behaviors associated with demands placed on children to eat foods beyond their taste preferences.
This researcher will conduct 10 hours of observations over a five-day period. Data will be collected during this period regarding the antecedents, behavior and consequences. At the conclusion of the observation a treatment will be used to modify the maladaptive behavior beginning on day six. Data will be recorded and held in escrow until all trials with all children is completed. An evaluation of the treatment will be conducted to determine if measurable progress has been made. Treatments will be used for a minimum of 60 days (Cooper et al., 2007 Kerwin et al., 2005).
Time sampling will be used to monitor and record any changes to behavior at stages of progression.
Operational Definition of Variables
Operational definition helps in identifying one or more observable events or habits about autistic children which will further help us in devising a measure for such behavior. The findings and conclusion will be directly affected by the manner in which we chose the operation. It is worth emphasizing here that the operational definitions must be valid and reliable in order to produce credible findings during the study.
Unlike many studies, which will have several independent variables, only one is used in this research project. The FloorTime method (Greenspan Weider, 2006) will be used to determine if the poor eating behavior associated with autism can be modified. The researcher will attempt to reestablish the disordered developmental sequence by following the subjects lead through structured and unstructured situations.
A single dependent variable will be used in the study inappropriate eating habits. Three extraneous variables are important to mention as well as they will impact the independent variable time of day, types of foods, and the temperament of the participant (adequate rest, mood, health). The variables will be recorded on the ABC Data Form (Appendix B) during each treatment. Initial information will be gathered via the BFAS and Questionnaire (Appendix A), in which parents or caregivers will fill out prior to the start of the research.
Data Collection, Processing, and Analysis
Initial data will be collected on the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) and Questionnaire (Appendix A) (Linscheid, 2006). The parents or caregivers will provide their assessment of the eating habits of the participants both pre and post treatment. Additionally, behavior data will be collected on the Antecedent, Behavior, and Consequence observation form (ABC) (Appendix B). The ABC method was based on procedures described by Iwata (Carter et al., 2007) and includes demand and control conditions.
During the demand condition, the experimenter may present difficult tasks using a least-to-most prompting hierarchy. Independent and prompted correct responses are praised. During the control condition, the participant engages in a highly preferred activity (as determined by a prior preference assessment). Non-contingent attention is delivered on a fixed-time schedule, and no demands are presented. All problem behavior was ignored during this condition.
The ABC form (Appendix B) (Carter et al., 2007) is used to determine patterns in the occurrence of the antecedents, behaviors and consequences that relate to the problem behavior. ABC analyses are often quite useful in developing initial hypotheses or summary statements of the childs challenging behavior. Antecedents are the conditions that immediately precede the occurrence of the childs behavior (Cooper et al., 2007). Antecedents include the specific times of day, settings, people, and activities that either occur or are present before the child exhibits challenging behavior. The term behavior refers to the childs challenging behavior-what the child is doing, how often the behavior occurs, the length of the behaviors occurrence, and the intensity of the behavior (Reed et al., 2007). Consequences refer to the events that immediately follow the occurrence of the childs challenging behavior. Examples of consequences include the attention paid by an adult in response to the childs behavior, as well as the activities and object the child either escapes or has access to as the result of the behavior (Reed). At the conclusion of the study, a comparison of this strategy based on treatment data will be formulated. All data will be placed in line graphs and statistical charts. The entire study will be conducted in the natural residential setting for the child.
Methodological Assumptions, Limitations, and Delimitations
The goal of behavior modification is to achieve balanced responses to introduced tasks. However, negative implications can develop with the use of this strategy. With the introduction of new contingencies that surround the maladaptive behavior, the child may become frustrated and upset, particularly since the previous pattern of response functioned less effectively than in the past. It is likely that the child will test the limits and will experience extinction bursts where behaviors get worse before it gets better or which may re-emerge under novel or challenging circumstances.
To identify behaviors that require change, and to teach acceptable replacement behaviors represents a time consuming process for both the parentcaregiver and the child. If used, however, this process has proven successful for several populations, i.e., autistic children, mental health professionals, parents, etc., individuals and in the educational setting. The keyword to effectively work with this process is consistency and routinicity basic tenets in Behavior Modification especially working with ritualistic behavior. By consistent adherence to a pattern of positive reinforcement, behaviors can be taught that will benefit the child in hisher efforts to meet social expectations.
True independent variables provide greater internal validity. The present study maybe confounded by extraneous variables such as time of day, types of foods or the temperament of the participant, just to name a few. The absence of random assignment reduces overall internal validity. Since random assignment cannot be performed there is no guarantee that the root cause of the behavior can be found.
Several strengths in this proposed study are identified. The individual difference in multiple sets of measurements is not relevant, as it is taken care by the error variance. Replication of the measurement helps in arriving at the most accurate figure under the circumstances, as the average of multiple measurement figures proves to be nearest to the reliable finding (Borden Abbott, 2008).
Additionally, this design permits the experimenter to test for causal relationships between variables instead of just correlational relationships. A weakness in this study is that the experimenter cannot study interactions among variables and sample may not be representative of extraneous variables as well as observer biases (Borden Abbott, 2008). As in this study true experimental designs are often somewhat contrived situations that do not always mimic what happens in the real world. Thus, the degree to which results can be generalized across situations and to real world application is limited (Witwer Lecavalier, 2005).
Other limitations to the study include challenges associated with validity. True independent variables provide greater internal validity. This experiment maybe confounded by extraneous variables such as time of day, types of foods or the temperament of the participant, just to name a few. The absence of random assignment severely reduces overall internal validity as well. Since random assignment cannot be performed there is no guarantee that the root cause of the behavior can be found.
Did the health professionals, psychiatrist and psychologist, perform a proper and accurate initial diagnosis The time of day, types of foods or the temperament of the participant may confound the study with these extraneous variables. Additional limitation includes the lack of a viable measure, which tells whether the caregivers, therapists and practitioners truly understand the FloorTime training and whether the implementation of the intervention was performed correctly.
Ethical Assurances
Since the study requires participation of human subjects, requisite consent from the participants and confidentiality about the privacy and data holds significant importance for the study. During the studies of such nature, sincere efforts are required to be made to communicate the aims and objectives of the study to the participants. This can be done by forwarding a note about the study along with the questionnaire or the consent form.
The proposed study meets APA ethical guidelines and Northcentral IRB process. Since all of the participants in the study are minors, parental consent will be required before the experiment begins. Parents will be informed regarding the rationality of the experiment and the exact procedures to be followed. Parents will also be given copies of the program in case they have objections to it. All participants will be informed in advance of the procedures for the experiment (Corey, Corey, Callahan, 2006). Contact details of the researcher, and the university authorities will also be provided to the parents of the research participants, so that if some of them wish to seek more information about the study, they can do so at their own convenience. Acquiring informed consent is very important for carrying out any study. Such a consent document serves as protection both for the participants and for the researchers involved.
Summary
Carrying out the research in a methodical manner, by properly documenting the methods and findings, helps in heading towards a firm and systematic research study. In this particular study, one can never be sure about the kind of reaction an autistic child will give in response to certain situation. Therefore, observing the situation will prove to be the key for data gathering. While secondary data will be collected from literature review and peer reviewed journals, observing the behavior will be the key source of primary data.
The proposed study will be conducted through the use of a quasi-experimental method of research and a one way within subjects ANOVA with intervention (treatment versus control) (Bordens Abbott, 2007). Data will be collected from the primary caregiver of the participant and recorded on the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) (Appendix A) (Linscheid, 2006). When the trial begins, data will be collected over a period of 5 days (observation period) utilizing the Antecedent, Behavior and Consequences (ABC) (Appendix B) (Carter et al., 2007) and then the information will be added to the Data Analysis form (Appendix C) (Riffel, 2009).
The FloorTime (Greenspan Weider, 2006) method will be used with autistic children under the age of 8 years old, who are non verbal and who have a self-limiting diet of very few foods (one to two types of food which may not have any nutritional value). A licensed practitioner, (psychiatristpsychologist) have diagnosed the selected participants with Autism within the past 3 years. The eating behavior will be evaluated with the use of AB design and will consist of an observation period, treatment period and several periods of evaluation. The participants for this study cannot be randomly assigned from among all autistic children but will be selected from available residential locations within an assigned geographical area.
At the conclusion of the observation period, the treatment, FloorTime, will be introduced to the participant followed by an evaluation of the participants reaction to the treatment over a 60-day period. The participants behavior will be monitored through the 60-day period and all behavior will be tracked and placed in line graphs and statistical charts. The entire study will be conducted in each participants home.
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