July 25, 2008 2:08 pm Published by Francisco Monegro, Ph.D., M.D.
Parents and staff often ask these questions when they are witness to an autistic adult individual who is engaged in what psychologists call, problem behaviors. An autistic individual may be hitting or punching himself or others, throwing a tantrum, running away (elopement), screaming or yelling loud in an agitated manner or assaulting others in different ways.
There are two major frames of thought for analyzing these problem behaviors. We can think of them from a biological perspective, that is, view the behavior as a result of brain dysfunction and biochemical imbalances. We can also view these problem behaviors from a social environmental perspective (Bauman & Kemper, 2004; Hollander & Evdokia, 2007; Iwata, Vollmer, & Zarcone, 1990).
At this time, I would like to focus solely on the latter social environmental perspective and discuss the role the social environment plays in the occurrence and recurrence of severe problem behaviors. To begin answering this question, we must analyze not just the behavior itself, but also the sequence of environmental events surrounding that behavior. This type of analysis is what we call a functional behavior analysis, whereby we assess the role of the social and physical context and consequences (observable/measurable events) that surrounds the severe problem behaviors. The reason for analyzing the surrounding events is that this perspective assumes an existing relationship between the behavior and the environment. Another way of understanding this relationship is to view the severe problem behaviors as purposeful and working within a function of antecedent contexts and consequences (if “X”, then “Y”). For instance, when an autistic individual becomes agitated or self-abusive, most of the time a family member or staff will give him more attention, which may be what he wants. This relationship between the self-abusive behavior and “attention giving” may become strengthened, conditioning the maladaptive behavior by the positive consequences. Thus, a functional analysis accounts for the fact that social environmental events can either trigger or give purpose to the maladaptive behavior (Center for Autism and Related Disabilities, SUNY, 2008).
We can have two types of consequences to a maladaptive behavior: a positive reinforcement or a negative reinforcement. By using the words positive and negative, I do not make any value judgment about these reinforcers, meaning that I say nothing about whether they are “good” and “bad” things. Positive reinforcements are environmental stimuli that are introduced immediately after the behavior and subsequently increase the likelihood of occurrence of a particular behavior. For example, if an autistic individual gets agitated and a staff member takes him for a walk- an activity that he enjoys-, it is likely that through time the agitated behavior may increase in frequency and possibly intensity. The effect of the staff providing a walk to the autistic individual, contingent upon the agitation increases the frequency of the behavior over time. In this example there exists a temporal relationship between the behavior and the positive consequence of going for a walk. Therefore, we can say that the autistic individual learned how to get a walk with staff, by getting agitated (Austin and Carr, 2000; Cooper, Heron and Heward, 2007.)
Negative reinforcements are aversive environmental stimuli that are removed immediately after the behavior and subsequently increase the likelihood of occurrence of a particular behavior. Negative reinforcements are often seen in problem behaviors when we engage an autistic individual in task demands and compliance situations. The autistic individual tries to escape from a situation because it becomes an aversive event to him or her. It can consequently be negatively reinforced when that event or demand is removed, which may make the maladaptive behaviors more likely in the future. For example, an autistic individual may throw herself on the floor to avoid going back to engaging in a task. The negative reinforcer in this case would be the consequence of no longer engaging in that task as a response to this maladaptive behavior. Occasionally, self-injurious behaviors follow a negative reinforcement function and the misunderstanding of the behavior may lead to an unintentional escalation of the behavior. Therefore, it is imperative to perform an accurate functional analysis to understand the behavior because in the case of self-injurious behaviors the plan of ignoring the behavior may seem to be a good strategy for changing the behavior if the motivation (function) for the behavior is to seek attention, but it could be that the individual’s contingency relationship (temporal cause-effect relationship) may be characterized differently. In another situation, an autistic individual may choose to engage in self-injurious behavior to avoid complying with staff instructions, for instance, to do laundry, take a shower or attend his day program. The autistic individual maintains his or her own non-compliance behaviors by negatively reinforcing that behavior through escape and avoidance of the aversive stimulus, such as doing laundry. In this scenario, we could try to modify the behavior not by ignoring it, but by increasing the motivational components of the low non-preferred activity to do laundry. Occasionally, a poor management of this situation may escalate to verbal and physical aggression and property destruction (Repp and Horner, 1999).
There are different contingencies that may strengthen severe problem behaviors such as attention-seeking, obtaining tangible items (e.g. food), escape-avoidance from a difficult task and self-stimulation (boredom or lack of structure) (Center for Autism Spectrum Disorder, 2005). If parents and staff members can understand the function of the severe problematic behaviors, they can change the stimulus that maintains the maladaptive behaviors and subsequently work to alter the frequency and motivational conditions of these problematic behaviors.
July 9, 2008 5:04 am Published by Francisco Monegro, Ph.D., M.D.
High-Functioning Autism (HFA) has been a controversial term which occasionally refers to and sometimes is used interchangeably with Asperger’s Syndrome and Pervasive Developmental Disorder, not otherwise specified (PDD, NOS). Great confusion and controversy about the definition of High-Functioning Autism (HFA) continue, with the main issue being whether or not Asperser’s Syndrome is truly distinct from autistic disorder (Asperger, 1944; Wing, 1981; Baron-Cohen, 2002; Freeman, et. al. 2002; Klin, et. al. 2000; Volkmar & Klin, 2001; Young & Brewer, 2002). Goldstein, et. al. (2002) stated that the diagnostic criteria between Asperger’s Syndrome and High-Functioning Autism (HFA) overlap and are unclear according to the DSM-IV (1994). Blacher et. al. (2003) stated that “definitional and boundary issues are major research concerns in the area of Asperser’s Syndrome and High-Functioning Autism (HFA). The term Asperger’s Syndrome was first described by Dr. Hans Asperger in 1944, but was not widely used in the
United States until after 1981, when his work was translated into English. In addition, when classification of Asperger’s Syndrome is compared in the DSM-IV and ICD-10 with PDD, NOS, Dr. Szatmari (2000) considers that the conceptualization is deeply unsatisfying to many parents, front-line clinicians and academic researchers. Given that HFA is not classified in the DSM-IV or ICD-10, some would say that it isn’t a diagnosis.
In 1991, Dr. Frith in her book “Autism and Asperger’s Syndrome” mentions that many professionals felt Asperger’s Disorder was simply a milder form of autism and they used the term “High-Functioning Autism” to describe these individuals. Dr. Szatmari stated that by not specifying symptom differences, the differentiation of Asperger’s Syndrome from High-Functioning Autism becomes confused. Eric Schopler et. al. (1992) in his book, High-Functioning Individuals with Autism, proposed that Asperger’s Syndrome and High-Functioning Autism did not have any difference and he recommended that the term Asperger’s Syndrome be discarded. Wing (1998) concluded that Asperger’s syndrome and High-Functioning Autism were synonymous and stated that Asperger’s Syndrome and High-Functioning Autism are not distinct conditions. She recommended that Asperger’s Syndrome be used for “children and adults who have autistic features, but who talk grammatically and who are not socially aloof”.
Moreover, Ozonoff, et. al. (2000), suggested that Asperger’s Syndrome and High-Functioning Autism involve the same fundamental symptomatology, but differing only in the severity. According to Gilbert (1998), there are no widely accepted diagnostic guidelines specifically for High Functioning Autism (Gillberg, 1998). When individuals diagnosed with Asperger’s Syndrome are compared with those with HFA, they generally have lower Full Scale IQs, with less apparent Verbal/Performance IQ discrepancies.
Due to the confusion in the diagnostic criteria and definitions between Asperger’s Syndrome, PDD, NOS and High-Functioning Autism, Dr. Pomeroy (1992) presents a model for subtyping the Pervasive Developmental Disorder (PDD). He suggested that it is justifiable to define three subtypes of PDD without mental retardation (a) a group with higher verbal skills than performance skills, b) a group with language impairment, and c) a group with non-language impairment.).
There is no consensus within the scientific community that Asperger’s syndrome is indeed separate and distinct from High-Functioning Autism. Also it remains unclear whether Asperger’s Syndrome is different from the autistic spectrum disorders. The Autism Society of America states that “more advanced”, “high-functioning”, or “mild” autism are subjective terms and that there are no clear clinical definitions for them. Researchers and clinicians are working to determine if Asperger’s Syndrome is a form of High-Functioning Autism or if it is a different entity with different etiology and treatment. The problem arises in individuals within the spectrum with borderline cognitive ability (IQ>70 or above) who sometimes are described as High-Functioning Autism. Some researchers report differences in verbal skills, for example, between Asperger’s Syndrome and High-Functioning Autism (Fitzgerald & Corvin, 2001). Some researchers are still using Asperger’s Syndrome interchangeably with High-Functioning Autism, while others use only High-Functioning Autism/PPD (HFPDD) (Kamio, 2007). However, making the diagnosis based on verbal skills or IQ differences are not supported by the research data (Fitzgerald & Corvin, 2001).
So, then, to return to the question: Who knows what is High-Functioning Autism? Based on the current status of the scientific knowledge and diagnostic classifications (DSM-IV & ICD-10), a lot of clinicians and researchers would say that they know the “right answer”- that is, they are the ones who know what is High-Functioning Autism (HFA) –, but without a much needed consensus of a differential diagnosis and treatment, the scientific community is unable to have a clear dialogue to better understand the phenomenon of High-Functioning Autism (HFA), Asperger’s Syndrome (AS) and Pervasive Developmental Disorder, not otherwise specified (PDD, NOS).
July 1, 2008 4:01 am Published by Francisco Monegro, Ph.D., M.D.
The pharmacological approach continues to be one of the important components of a comprehensive treatment for severe aggressive behaviors and self-injurious behaviors (SIB) in autistic individuals. One of the most captivating aspects of these severe problematic behaviors is their uncertain etiology. Severe aggressive behaviors and self-injury behaviors (SIB) can result in significant harm to individuals with autism and distress for their caregivers and families.
Parikh, Koleyzon and Hollander (2008), from the Mount Sinai School of Medicine, NY, reviewed twenty one trials with 12 psychotropic medications selected from randomized placebo-controlled trials studies and only five psychotropic medications produced significant improvement when compared to placebo [Tianeptine, Methylphenidate, Risperidone, Clonidine, and Naltrexone.] Of these five medications, only Risperidone and Methylphenidate demonstrated results that have been replicated across at least two studies.
While no single drug or class of medication has yet emerged as consistently effective for the treatment of severe aggressive and self-injurious behaviors in autistic individuals, however, Ratey et. al. (1987) showed that Beta-blockers have a remarkable effect in diminishing the occurrence of severe aggressive and self-injury behaviors. In an “open label” study that evaluated several drugs used to treat self-injurious behaviors, Clonazepam, Propranolol, Sertraline and Clomipramine showed observable control of the problematic behaviors (Luiselli, et. al. 2000).
In the Central Institute of Mental Health, Child and Adolescent Psychiatry,
Germany, Rothenberger (1993), reported that by using Sulpiride (Benzamide derivative) self-injurious behaviors was significantly reduced in several individuals with autism. (Sulpiride is a selective dopamine D2 antagonist with antipsychotic and antidepressant activity).
I think while several studies indicate that Risperidone, Methylphenidate, and a combination of a beta-blockers (Propranolol) or alpha-blockers (Clonidine) and a Selective Serotonin Reuptake Inhibitor (SSRI) (Sertraline or Clomipramine) may be effective in reducing severe aggressive behaviors and self-injurious behaviors, however, additional placebo-controlled trials are needed on other potential drugs to increase the number of therapeutic options available in the treatment of severe problematic behaviors in individuals with autism.