Apllication of Cognitive Theories When Working with Individuals with Autism Spectrum Disorder

‘Autism is a lifelong, developmental disability that affects how a person communicates with and relates to other people and how they experience the world around them’. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published in 2013 provides a ‘more accurate, and medically and scientifically useful way of diagnosing individuals with autism-related disorders’. People with autism in the past were diagnosed under the fourth edition of the criteria DSM-4 by identifying differences in the underlying ‘triad’ of behaviours. This triad of impairments included difficulties with social interaction, social communication and social imagination. Within DSM-4, diagnosis fell under four separate disorders: Autistic Disorder, Asperger’s Disorder, Childhood Disintegrative Disorder and Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS). Consequently a wider, broader spectrum of criteria for diagnosis with DSM-5 (2013) has now combined these four areas into a single category – Autistic Spectrum Disorder. The previous 3 areas of impairment have been reduced to 2 main areas: Social communication and interaction; and Restricted, repetitive patterns of behaviour, interests, or activities. With this dyad of impairments, people with a diagnosis may also present with unusual sensory responses.

Profile of Autistic Individual

Greg is an autistic individual with whom I work with, as an ASD class teacher, on a daily basis in a second level school with an ASD unit attached. Greg is currently a 14 year old boy with a diagnosis of ASD and a comorbid diagnosis of Attention Deficit Hyperactive Disorder (ADHD) and attends an ASD unit in a small group class with number of other students of the similar age. He presents as an engaging young man, with difficulties including attention, emotion and sensory regulation, essentially exhibiting a complex and fluctuating profile of behavioural difficulties. The first impairment of deficits in social communication and interaction, Greg displays with inappropriate conversation and he can point out faults in others. Greg demonstrates a lot of difficulty in differentiating strangers from familiar people. He exhibits significant concrete thinking. For example he has no awareness of ‘stranger-danger’ and can become confused when parents or teachers speak as they are trying to teach him ‘stranger-danger’ awareness.

Along with his multiple diagnosis, Greg presents with moderate-severe language difficulties, characterised by severe receptive language difficulties and moderate expressive language difficulties. With the second impairment of restricted behaviours, interests and activities, Greg displays a degree of obsessiveness and very rigid patterns of behaviour. On a daily basis, Greg can be very pleasant and easy to engage with as long as his demands are being met. At times he may show significant intolerances for demands that contradict his preferences and this leads to a difficulty in accepting unwelcome transititions or changes. Greg can become very overwhelmed with the level of stimulus in a classroom, he finds noise and close interaction with people very difficult to handle. His level of obsessiveness can be displayed with his collection of teddy bears; this is a good example of how he finds it hard to regulate himself. He will become fixated on the need to have a teddy bear from a claw machine. Along with these two impairments, a component of sensory responses may also be evident. In Greg’s case, I have observed his behaviour fluctuate between three states. These three states present as:

• Stable level: Greg is able to listen and respond to firm verbal boundaries, however remains at risk of becoming dysregulated. He can become anxious and is a movement seeker.
• High level: Greg presents in a constant fight or flight mode. His behaviour can be extremely dysregulated, hyper, acting out and impulsive. Calming activities and focus on breathing may be accessed if he tires.
• Lethargic level: Sometimes Greg becomes demotivated and defiant. In these occasions he responds well to fun making and competitive team games, framing it as helping an adult with whom he has a good relationship with.

Cognitive Theories

From Bleuler’s initial definition of autism (1911), clinicians have been on a journey with their research on autism. It is evident that an understanding of the cognitive processes involved in the condition has been the main reason for majority of the research. Smalley et al, (1988) discussed that even though genetic factors play an important role in the occurrence of this condition, diagnosis is made on the basis of behavioural analysis and examinations. From Kanner (1943), Aspegers (1944), Baron-Cohen et al. (1985), Happé (1994), Milton (2012), and Frith (2015), a number of cognitive theories have been formulated to better explain about autism. In recent psychological research the three most noticeable theories are; a deficit of theory-of-mind, executive dysfunction. These three theories (theory-of-mind, executive dysfunction and weak central coherence) have painted a clear and precise picture of the nature of ASD.

The first cognitive theory I will is discuss is Theory of Mind (ToM). Rajendran & Mitchell, (2007) refers to an autistic individual having an impairment in the development of social cognition. This suggests that individuals with autism fail to understand and take into consideration other’s mental states or points of view. Frith (2015) refers to a person’s ability to read facial expressions, to empathise, to imagine other people’s thoughts and feeling. Individuals with ASD have been noted to have an under-developed ToM, therefore having difficulty in analysing other people’s thoughts and feelings, and struggle with empathising. Both of these hypothesis can account for most of the behavioural, social and cognitive deficits presented, it would appear to fail in offering an explanation for behaviours such as insistence on sameness, repetitive behaviours and transitions from one task to another.

Research suggests there are two components of theory of mind: a cognitive component, knowing intuitively that something is wrong with another and emotive, the inability to feel pain or distress of another. It has been found that individuals with autism display impairments in the cognitive and not in the emotive. Research indicates that the individual is capable of having an emotional reaction to this distress once they understand that the other person is in distress. Greg displays these two components of ToM quite clearly. When he presents in a stable regulated state, there is evident understanding of distress and joy in others. In the previous academic year, we completed as a class group ‘The alert programme – How does your engine run’. On a daily basis we use the scale described as ‘running high’, ‘running just right’ and ‘running low’, based on self-regulation throughout the day. All teachers, Special Needs Assistants and students participate. On the occasion that a person will be ‘running low’, Greg will enquire why and he will display an appropriate emotive response to the distress of that person. Grandin refers to having emotions but ‘they are more like the emotions of a child than an adult’ (2006). It would appear that Greg displays emotions in a similar manner as Grandin describes as ‘childhood temper tantrums were not really expressions of emotion so much as circuit overloads. When I calmed down the emotion was all over’.

The second cognitive theory I will discuss is Executive Function (EF). EF can be described as a set of cognitive processes that are involved in the organisation and control of mental and physical activity. As such it is the skills that are required for goal directed behaviour; skills such as managing time, managing own behaviour, planning and organising, problem solving and making decisions and choices. Schaber (2015) refers to EF in people with ASD, as individuals experiencing ‘executive dysfunction’. A person when given a task to do may know that they have a job to do but not be able to start, break down or stay on task. Greg exhibits immense difficulties in EF, on majority of tasks. I question the addition of the comorbid diagnosis of attention deficit hyperactive disorder (ADHD) adding to his dysfunction. Kutscher (2005) describes EF as the skills required to make a plan and actually execute it. It is evident that there is an overlap in deficits in skill areas. Barkley (2000) describes executive functions to include; the ability to inhibit, working memory, foresight, hindsight, organisation, self-talk, sense of time, transitioning for agenda A to agenda B and separating emotion from fact. It is evident that these symptoms are not just incidental and are commonly seen in both diagnosis of ASD and ADHD. In Greg’s case, EF’s across the board are very poor. However with task analysis and breaking each task down into small achievable steps, some success has been evident. Greg thrives on structured activities, a daily visual schedule provides support throughout the day.

On an everyday level, foresight can be the most essential EF. It refers to the ability to predict one’s future needs. For Greg any behaviours exhibit do not seem to warrant consequences. He presents very much in the here and now, with neither the past or the future having a huge impact on modifications of behaviours. Greg demonstrates deficits in separating emotion from fact. In the past he has travelled on a bus to school with a small number of students with additional needs, in the company of a bus escort. When met with a traffic jam, Greg does not see this as a relaxing moment but can become quite anxious and displays heightened behaviour. This is also evident in his inability to wait, therefore underpinning a shortfall in foresight and the need for tasks to happen immediately and his need for the teachers attention majority of the time.

Cognitive Theories and Interventions

Boucher attributes the aims of ‘treatment of people with ASD are to facilitate development and to increase and individual’s competencies and control over their own lives. ’ (2017). Research shows that intervention can greatly improve an individual’s developmental outcome. Interventions need to be chosen wisely, as some may not have the desired effect. For the most part it is often a multi-disciplinary outlook that is required for interventions, with not just one intervention outstanding, yet a holistic view must be taken. A successful response to an intervention is evident when it is delivered in a safe, familiar environment by a professional where a good relationship and a sense of trust has been built. Greg uses a visual schedule at home and during school time, this offers a sense of plan and that nothing unexpected could happen on a given day. Colour-coding of text books and exercise copies along with specific subject areas, aids with organisation in the classroom. Both of these interventions can aid with poor EF. Being mindful of the ToM deficit, Greg struggles with an awareness of his psychological self. He struggles to explore and execute changes in his internal thought process as he is not aware or them and cannot effectively monitor what they are responsible for.

Every morning, Greg completes a motor/sensory intervention. This intervention goes hand in hand with low arousal techniques to try to ensure that Greg remains in a stable state of regulation. Through a number of alerting, sensory seeking and calming activities it aids with executive dysfunction therefore improving concentration levels and everyday skills. This programme also includes deep pressure strategies. Greg has been encouraged to use a break card, when he feels high levels of stress or anxiety throughout the day. He is then offered a choice card of his favourite deep pressure activities. This will help him control, manage and regulate his behaviours in an over stimulated environment. It is apparent that a relationship exists between ToM and social and communicative challenges deep-rooted in individuals with ASD. In demonstrating social communicative shortfalls, it is no shock that those with ASD often fail to understand the communicative intent of classroom language. Likewise, the difficulties in pragmatics and in understanding deception may be contributing factors to the ongoing difficulties experienced in developing peer relationships. It may also explain the high incidence of peer shunning and victimisation those with ASD experience in school settings.

Poor EF may however impact on an individual’s behaviour and learning in the classroom. In the early years an individual with ASD is likely to have difficulties with inhibiting a response, working memory and using new strategies. As an individual gets older, difficulties in planning and organisation are apparent, as well as problems with time-management, prioritising, understanding abstract concepts and self-monitoring. Learning in the classroom may be hampered due to the individual's inability to shift between activities or mental state.

Conclusion

It is crucial to have an understanding of Cognitive Theories when working with individuals with ASD. In the classroom, ‘mindblindness’ will compromise socially mediated learning and in the case of EF, an inability to shift between activities impacts on learning. These are key needs of an individual that must be addressed.