[Autism Spectrum Disorder]

DR. JOANNE HOLMES: So this tutorialis going to be about the approaches of therapyto children with autism spectrum conditions.[Dr Joanne Holmes, Consultant Child Psychiatrist,Medical Director, Croft Child and Family Unit]We're going to talk a little bit about what an autism spectrumcondition is and define that.Then we're going to think about what the consideration shouldbe when you're approaching a therapeutic interventionwith a child with an autism spectrum condition.

DR. JOANNE HOLMES [continued]: I'm going to talk about what the range of therapeutic approachescould be and how we choose which one isgoing to be the most effective.[Autism spectrum]If we're thinking about what an autism spectrum condition is,we're thinking of autism spectrumas a neurodevelopmental condition.It's quite a common condition.We estimate that about 1% of the populationwill have such condition.

DR. JOANNE HOLMES [continued]: Autism is characterized by problemswith social understanding and social communicationand many people with this conditionwill also show quite repetitive or stereotyped behaviors.Children with autism spectrum conditionsdo have high levels often of anxiety.They find social situations quite daunting.

DR. JOANNE HOLMES [continued]: They may avoid social situations and use a range of behaviorsto manage the social demands that are made upon them.Children with autism spectrum conditionsmay have quite challenging behavior.They may find they want to do very repetitive behaviors.They may become very fixed on certain topicsand find it very difficult to followthe ordinary social rules that might apply either,for example, in the home environment or a schoolenvironment.

DR. JOANNE HOLMES [continued]: Some children will have very high levelsof sensory awareness and may becomequite distressed and anxious by beingin environments which are too noisy,for example, or in which there's too much movement.And that can lead on to behavioral problems as well.Many children will find understandingordinary conversational language difficult.

DR. JOANNE HOLMES [continued]: In particular, they find metaphors or unclear languagevery difficult to understand.That might lead to them to become confused or distressedand again, contribute to them being unable to followordinary social rules.[Language level]The autism spectrum is very wide.It includes people with a learning disabilitywho may often have very little languageor spend most of their time being veryrepetitive in their behaviors.

DR. JOANNE HOLMES [continued]: And go across the spectrum to people who are extremely able,who have very high IQ's and may be extremely verbal,but still may struggle to manage the ordinary social demandsof life.Thinking a little bit more about the language difficultiesfor children with autism spectrum conditions.This is a very important area to getright is if you can adjust your language appropriately.

DR. JOANNE HOLMES [continued]: And this can help children understand and engagein communication much more effectively.For example, making sure your language is very directand doesn't have lots of metaphorin it or colloquialisms can reallyhelp an autistic individual feel much calmer and muchmore able to relate to you.

DR. JOANNE HOLMES [continued]: [Key approaches]A key difficulty for many children with an autismspectrum condition is that they havegreat difficulty understanding another person's perspective.They find it very difficult to put themselvesin somebody else's shoes.We call this a difficulty with Theory of mind.This can often lead to difficultiesas it's a key reason why childrenwon't follow social rules.

DR. JOANNE HOLMES [continued]: There are a range therapies you can consider when approachingthis sort of situation.One of the first decisions is to decide whether you'regoing to work primarily with the parentsor more directly with the child.Sometimes these approaches can both be happening in parallel.An approach you might mainly use in the parentswould be a behavioral therapy approach.Where as direct approaches with the childmight include creative therapies or, for example,a CBT approach or psychodynamic approach.

DR. JOANNE HOLMES [continued]: So when we're meeting a child and a family who are strugglingand there's an autism spectrum condition involved,we would need to consider the nature of the difficultiesas they're experiencing and, of course,the level of ability of the childand their language level so we candecide what kind of therapeutic approach will be effective.Say, for example, with a child who has very low languagelevels a therapy that doesn't have a high verbal demandwould be appropriate to somethinglike, for example, music therapy or play therapy mightbe more appropriate.

DR. JOANNE HOLMES [continued]: Whereas with a person who has very good verbal skillsit might be appropriate to use a more cognitive approachsuch as cognitive behavioral therapy.So, for example, if the parent saysher child has a major temper tantrum every timeshe tries to stop him playing on his video games,then we'd really have to think about an approach thatwould help the child and the familymanage their use of that game.

DR. JOANNE HOLMES [continued]: So for example, you might suggest that the child is onlyallowed to play the game after they'vedone a task that the parent wants them to do.That would be using a behavioral approach.On the other hand, if you discover talking to your familythat their child displays their most distressed behaviorfor example, every time they go into a supermarketwhere it's very noisy, then that might give youa clue that there are sensory issues that you needto take into account when consideringhow to manage that distress.

DR. JOANNE HOLMES [continued]: Another example might be a child whoshows their most prominent difficulties say, for example,when they're in a social situation and say,for example, a teacher's giving instructionsand they're failing to understand these.And they may use behaviors that are designed to reducethe demand from the teacher.

DR. JOANNE HOLMES [continued]: So every time the teacher asks them to do some writing,for example, they might have a tantrumor try and leave the classroom.That would be an example of whereit's the cognitive demand on the child that'sdriving their difficulties.One of the issues when embarking on therapy with childrenwith autism spectrum conditions is the expectationsof that therapy.

DR. JOANNE HOLMES [continued]: Obviously, parents want the best for their childrenand they often have high hopes that a therapeutic interventionwill make a very big difference to the child's functioning.Often it's important to really explain to parentswhat the focus of the therapy is and the limitations of thatas well as what you want to achieve.In the setting where I work at the Croft,often we see children in crisis and families in crises.

DR. JOANNE HOLMES [continued]: Often, in particular, the familiesare under huge amounts of pressure and strain.In our setting we find that family therapyis extremely valuable.This is a therapy that can give every member of the familya voice and help families look at the patterns thatare emerging and particularly think about how their child'sdifficulties might be impacting on every member of the family.

DR. JOANNE HOLMES [continued]: [Therapy outcomes]If therapy is successful it may bethat you achieve very small differencesfor a child or a family, but these might havea huge impact on that child.So for example, if a child is able to,for example, manage to go to a supermarketwithout having a major tantrum, thatcould make a big difference to howa family can manage their ordinary day to day routines.

DR. JOANNE HOLMES [continued]: Other things that we find really helpfulare just helping the child have a high level of self esteemand confidence in their ability.So if a child, for example, has been out of schoolfor a long period of time and they can attend a schoolwith support, this can suddenly open up a whole world for themthat they thought they couldn't access.And what we also find is that if parents can reallythink about how the world looks from their child'spoint of view, this can really help them to sometimes toleratevery difficult behaviors and respondin a much more calm, proactive, and supportive way.

DR. JOANNE HOLMES [continued]: And again, that can make a huge impacton a child's outcome in the longer time.Something I've discovered over time that's helpfulwhen working with people with autism spectrum conditionsis to keep your language very simple and direct.To keep it slow and to give plenty of timefor people to think and process the informationthat you're giving them.

DR. JOANNE HOLMES [continued]: [Key pointsDifficulties faced by people with autismAutism is a common conditionRange of difficultiesTherapeutic approachesPlanning intervention]We've talked about the kind of difficultiesthat people with autism spectrum conditions can present with.We've talked about how common the condition isand how wide a range of difficulties people can have.