Autism spectrum disorder (ASD) is a neuro-developmental disorder that is characterized by two distinctive behavioural patterns, the impairment of social communications/interactions and manifestation of repetitive, restricted and unusual behaviour(Perera, Jeewandara, Guruge, & Seneviratne, 2013). The issues presented by the child in the case study like communication deficits, behavioural issues and lower vocabulary and speech issues among others indicates that the child, Kevin is showing signs and symptoms or “red flags” of Autism Spectrum Disorder. In order to establish a proper diagnosis of the child a diagnostic criterion should be referred. In recent times ASD is considered to be one of the mostly identified behavioural disorders in Children.
A. What are the psychosocial problems you identify in this case? Critically review the issues identified with regard to the nature of the case.
There are several psychosocial problems which are identified in this case. They range from psychosocial problems that have affected the mother during her pregnancy to the issue the family and the child are currently facing.
Both the parents of the child are coming from a low socio-economic background. Both parents have had poor education with the mother educated up to Ordinary Level and father up to year nine. The parents also lack support from their families as the father being an orphan and the mother maintains poor contact with her family, lack of support could adversely affect both the health of the mother and the developing child. Sri Lankans vastly rely on the support of the existing family, especially when they have a child. As the father was lining in an orphanage since aged seven it could have affected him in an adverse manner psychologically.
During the pregnancy, the mother has undergone a considerable amount of stress due to several implications. She hasn’t had much time to rest, relieve stress or to take care of herself due to her busy work schedule, she has lacked spousal support as her husband was mostly away because of his job requirements, hence she was lacking the much needed physical and emotional support. When the mother undergoes psychological stress during pregnancy it will have adverse effects on the neurodevelopment of the child, which could be a causative factor of the child developing ASD (Walder et al., 2014).
Her prenatal clinic attendance was poor, their busy work schedules presented as the causative factor. Due to irregular nature of checkups, any developmental abnormalities of the foetus could have been missed.
The mother was working at a paint manufacturing plant for the past 15years up to now, which includes the time of conception and delivery, this could have had some adverse effects on the foetus as well as the development of the child after birth (Felicetti, 1981) states that there is a significant connection between occupational chemical exposure and birth of autistic children.
Child’s mother, Nirmala, was bleeding infrequently during the fourth and fifth months of pregnancy and was induced at 35 weeks of gestation. Mother was 37 years old which is a risk during pregnancy and has had adverse gynecological factors including possible foetal distress and prenatal maternal stress. Research shows that these factors raise the possibility of the child developing autism spectrum disorders (Deykin & MacMahon, 1980; Glasson et al., 2004). The case study also states that the mother suffered from frequent viral infections possibly due to environmental factors and poor nutritional conditions.
Due to unsuccessful breastfeeding and problems of latching on, there is a possibility that the child could have been malnourished, research suggest that a possible causative factor of ASD could be deficiency of riboflavin or cognitive vitamins like thiamine or Vitamin D (Shamberger, 2011) which the child might have lacked.
B. Give consideration to what action you would take next if you are the trainee counselor in clinic, what are the guidelines to which you would refer and why?
After identifying all the causative factors from the history presented by the child’s parents I will be referring to the Fifth Edition of the Diagnostic and Statistics Manuel of Mental Disorders (DSM)(American Psychiatric Association. & American Psychiatric Association. DSM-5 Task Force., 2013) to reach a tentative/probable diagnosis. DSM is the handbook used by health care professionals as the guide to diagnose mental disorders. DSM contains the criteria for diagnosing mental disorders and helps to establish a consistent and reliable diagnosis.
DSM-V diagnoses ASD with respect to 2 main diagnostic criterions. The simplified diagnostic criteria and if it is applied to this child or not is indicated below.
a. Persistent deficits in social communication and social interactions across multiple context as demonstrated by the following, currently or in the past,
1. Shortcomings in social-emotional exchange – Kevin is laid back in conversations and has a very limited vocabulary. He struggles in normal emotional interactions with others.
2. Deficits in nonverbal communication and behaviour used for social interactions – There are no indicative signs given in the case study.
3. Hardships in developing, understanding and maintaining relationships – He shows difficulties in sharing, even his own mother with his sister, doesn’t like change of context like when his sister tries to change the games they are playing and is finding it difficult to have a friend.
After considering all these facts it seems at the first glance that he is at level 1 or 2 in the severity scale and will be requiring a substantial level of support.
b. Repetitive and restricted patterns of behaviors, interests or activities. Manifested by at least two of the following, currently or in the past,
1. Stereotyped or repetitive motor movements, use of objects or speech – Kevin shows impulsive behaviors and used to line up shoes and slippers around him.
2. Inability of adhering to change, sticking to strict routines or ritualized patterns or verbal/nonverbal behavior – Kevin has adamant food habits and prefers to eat pink food. He shows distress in small changes to his routine, like, change of play when playing with his sister.
3. Highly restricted and fixated interests that are abnormal in intensity or focus – he can spend many hours playing with his toys and forgetting those around him. He has a very keen interest on playing computer games.
4. Hyper or hypo reactivity to sensory input or unusual interest in sensory aspects of the environment – Kevin has an adverse response to loud and high-pitched noises. He is unable to tolerate loud noises and act out if encountered one.
Kevin presents signs of being in level two of the severity scale, and will require substantial level of support.
c. Symptoms should be presented in the early developmental period – Kevin showed many symptoms at a very early stage, derived from the ASD support site AutismSpeaks (“Learn the signs of autism | | Autism Speaks,” n.d.)Kevin was showing the following signs as an infant/toddler as presented in the case,
· By 6 months of age he was not smiling
· By 12 months he was not babbling – he started babbling at about 19 months
· By 12 months he was not responding to name calling – started at around 19 months
d. Symptoms cause clinically significant impairment in social, occupational or other important areas in daily living – Kevin’s symptoms do cause significant issues and distress on his daily living conditions and social interactions.
The next step after establishing a tentative diagnosis after referring to the DSM-V criteria is to do a quick analysis using an autism screening checklist to well establish the tentative diagnosis, as the case study only presents a snapshot for the entire case. These checklists get the parental input and helps the professionals to direct the children in to the best intervention pathway possible. Different countries use different checklists to further screen the child. If the child is in the early development stage it is advisable to use Modified Checklist for Autism in Toddlers – Revised (M-CHAT-R)(Robins, Fein, Barton, & Green, 2001). If the child has passed that stage one of the possible screening tests that could be used on them is the Childhood Autism Screening Test (CAST) or Childhood Autism Rating Scale (CARS).
Since Kevin is a seven year old, school going child and has not been diagnosed with ASD previously, he needs to undergo the Childhood Autism Screening Test (CAST) which was previously known as the Childhood Asperger’s Syndrome Test and was renamed and revised after the 2013 revision of DSM categorizing Asperger’s Syndrome under the banner of Autism Spectrum Disorder (ASD). CARS is designed to be used by more trained professionals with experience who will be directly observing the child for a long period of time, hence that will be used at a later stage.
After establishing a preliminary tentative diagnosis, then the child should be directed to relevant professionals to establish the confirmative diagnosis and a probable treatment plan. This aspect will be explained in the next question.
a. How would you approach the child and parents and the team of professionals when constructing on intervention?
After establishing the tentative diagnosis, the child needs to be directed to different professionals in order to construct and intervention and management plan. In a Sri Lankan context, especially with parents from a low socio-economic background and poor education it is extremely difficult to convey the impending needs of the child and it is likely that the parents will have no clear understanding about the disorder. One of the main factors is that there is a negative social stigma about mental disorders in Sri Lanka due to lack of understanding, hence, people would be very reluctant to accept a diagnosis of such a disorder. When approaching the child’s parents, it is extremely important to remember these facts and explain to them in such a way that they will be willing to continue with the given intervention plan. First of all, before beginning to the get the child involved, the parents of the child need to be properly educated as to what the probable condition is and the consequences of it if no intervention was done. It should be made clear to the parents about the child’s treatment plan so they can make sure that at least one of them could accompany the child in the future when he comes for his appointments.
When approaching the professionals with the child’s case it is important to ensure as the professional referring to have all the necessary information especially regarding the child’s history which is required to help them with the diagnosis, management and intervention.
b. How would you ensure your best professional involvement to support the child and the relatives?
It is vital in Sri Lanka to ensure that the parents are given the proper guidance irrespective of their socio-economic background. In this child’s case, it is well evitable that if they are well informed about the child’s condition, chances are that they will not satisfactorily comply with the management plan. In most Western contexts, there is a wide availability of literature, support groups and other support websites to help and guide the parents in the correct pathway. Unfortunately, in Sri Lanka state funded programs are not available for parents of Autistic children to better educate them to help their child grow and to help them to cope up with the child’s situation. So, helping them at this stage is extremely important.
The parents should be advised to focus on the positive cues which are exerted by the child rather than focusing on the negative. Parents should also have a lot of patience when interacting with the child and should not get disheartened by any drawbacks. They should have an open mind to understand that along with a single positive response that there might be more negative responses. They need to work according to a schedule, have a time table to do major/important chores/activities including play time during the day and need to be consistent with the schedule so that the child will be able to adhere to it over time. Spending some interactive play time with the child during the day is extremely important. It is also important to train the child to interact with others and slowly introduce the child to everyday activities. These points will be discussed with the parents and will come up with the best possible action plan to help the child out. The parents will be given confidence as to that they can always come in for support and to discuss about their child’s development. Parents will be educated on how to get the sibling involved in the whole plan as well.
The child’s school authorities will be informed about the diagnosis after confirming it with the professionals. Will have to coordinate with the school authorities in order to place the child in a special needs class if the school has one. If not, a school which has the facilities to accommodate special needs children will have to be sought out and help the parents to enroll the child in it and help the teacher to plan the syllabus to suite the child’s needs.
Depending on the management presented by the professional as a junior counsellor, the next step is to follow up with the parents and ensure that the child is getting all the help that he requires. It is really important to do this as the parents might have a tendency to give up after not receiving their intended outcomes from the intervention and treatment plans.
c. Who are the professionals about to involve in case management? Pay attention to Sri Lankan settings.
In an ideal setting the child should be referred an array of multi-disciplinary professionals for assessment.
· A child psychiatrist – a medical professional specializing in psychological issues of children to confirm the tentative diagnosis of the child.
· A developmental pediatrician – a medical professional who has special training in child development to observe, develop and manage the child’s developmental portfolio.
· A child psychologist or therapist – to present hands on support to the child and ensure that is getting enough therapy to slowly overcome his developmental red flags.
· A speech pathologist – to help the child with his communication deficits.
However, in the current Sri Lankan setting it is unrealistic to expect the child to get all the necessary support as Sri Lanka does not have any state sponsored health intervention programs for community with ASD (Perera, Jeewandara, Seneviratne, & Guruge, 2016). Given the current country context the possibility is that the child will be referred to pediatrician and a speech pathologist. It is highly doubtable given the financial status of the parents if they will be able to afford to enroll the child in any private facility which will be able to support the child with the required multi-disciplinary interventions.
D. What would you anticipate would be the outcome of your intervention? How would you evaluate its success? What could go wrong? What could you do to ensure best treatment outcome?
Patience is the key when treating a child diagnosed with ASD. The anticipated outcome of the intervention would be for the child to gradually improve his social communication skills and reduce his adamant and repetitive behaviours. In an ideal scenario is him willing accept certain changes in to his routine and throwing less tantrums when things don’t go his way. Another outcome which is vital for the development of the child will be attempting to improve his school education, improving his vocabulary is a vital part of this process. At the same time due to the intervention by the speech pathologist it is safe to anticipate a probable improvement in the child’s speech.
Case notes about the child will be maintained throughout the different intervention methods. As the counsellor, it is vital to collect the case notes from all the professionals involved in the management and keep track of it. The evaluation could be done by using a tool such as the Autism Treatment Evaluation Checklist (ATEC)(“Autism Treatment Evaluation Checklist (ATEC) | Autism Research Institute,” n.d.) which designed to be completed by the child’s primary caregivers such as parents, teachers, caretakers or study aids. This checklist comprises of the four most important subsets; speech/language communication, sociability, sensory/cognitive awareness and health/physical/behavior. Using this tool on a periodical basis would be an ideal way to keep track of the child’s development/improvement.
One of the main reasons that the intervention might not be successful is the fact that the parents might not have enough time in had due to their busy schedules to coach the child at home, as literature on managing Autism in Sri Lanka states that home based interventions are very successful compared to other types (Perera et al., 2016). Another issue might be lower financial statues of the parents and their inability to financially support all the necessary treatments and interventions for the child. Lack of a proper follow up and not making it to appointments would be among the factors that might affect the success of the intervention.
The best way to ensure that treatment was done is to have a follow-up schedule. Also, it is vital to make sure that different professionals interact with each other during the intervention