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Chapter 31: Child Psychiatry
Congenital Deafness or Hearing Impairment
Because children with autism spectrum disorder may appear
mute or lack language development, congenital deafness and
hearing impairment must be considered and ruled out. Dif-
ferentiating factors include the following: infants with autism
spectrum disorder may babble only infrequently, whereas deaf
infants often have a history of relatively normal babbling that
then gradually tapers off and may stop at 6 months to 1 year
of age. Deaf children generally respond only to loud sounds,
whereas children with autism spectrum disorder may ignore
loud or normal sounds and respond to soft or low sounds. Most
importantly, audiogram or auditory-evoked potentials indicate
significant hearing loss in deaf children. Deaf children usually
seek out nonverbal social communication with regularity and
seek social interactions with peers and family members more
consistently than children with autism spectrum disorder.
Psychosocial Deprivation
Severe neglect, maltreatment, and lack of parental care can lead
children to appear apathetic, withdrawn, and alienated. Lan-
guage and motor skills may be delayed. Children with these
signs generally improve when placed in a favorable and enriched
psychosocial environment, but such improvement is not the case
with children with autism spectrum disorder.
Course and Prognosis
Autism spectrum disorder is typically a lifelong, albeit hetero-
geneous, disorder with a highly variable severity and prognosis.
Children with autism spectrum disorder and IQs above 70 with
average adaptive skills, who develop communicative language
by ages 5 to 7 years, have the best prognoses. A longitudinal
study comparing symptoms in children with high-IQ autism
spectrum disorder at the age of 5 years, with their symptoms at
age 13 through young adulthood, found that a small proportion
no longer met criteria for autism spectrum disorder. Most of
these youth demonstrated positive changes in communication
and social domains over time. Early intensive behavioral inter-
ventions have been found to provide a profound positive impact
on many children with autism spectrum disorder, and in some
cases lead to recovery and function in the average range.
The autism spectrum disorder symptom areas that do not
seem to improve substantively over time with early behavioral
interventions are related to ritualistic and repetitive behaviors.
However, currently, evidence-based behavioral interventions
specifically targeting repetitive behaviors may ameliorate them.
The prognosis of a given child with autism spectrum disorder
is generally improved if the home environment is supportive.
Treatment
The goals of treatment for children with autism spectrum disor-
der are to target core behaviors to improve social interactions,
communication, broaden strategies to integrate into schools,
develop meaningful peer relationships, and increase long-term
skills in independent living. Psychosocial treatment interven-
tions aim to help children with autism spectrum disorder to
develop skills in social conventions, increase socially accept-
able and prosocial behavior with peers, and to decrease odd
behavioral symptoms. In many cases, language and academic
remediation are also required. In addition, treatment goals gen-
erally include reduction of irritable and disruptive behaviors that
may emerge in school and at home and may exacerbate during
transitions. Children with intellectual disability require devel-
opmentally appropriate behavioral interventions to reinforce
socially acceptable behaviors and encourage self-care skills.
In addition, parents of children with autism spectrum disorder
often benefit from psychoeducation, support, and counseling in
order to optimize their relationships and effectiveness with their
children. Comprehensive treatment for autism spectrum dis-
order including intensive behavioral programs, parent training
and participation, and academic/educational interventions have
provided the most promising results. Components of these com-
prehensive treatments include expanding social skills, commu-
nication, and language, often through practicing imitation, joint
attention, social reciprocity, and play in a directed but child-cen-
tered manner. Five randomized controlled trials (RCTs) of early
intensive comprehensive behavioral interventions targeting core
features of autism spectrum disorder in children ranging in age
from 2 years to 5 years of age have shown increases in language
acquisition, social interactions, and educational achievement at
the end of the study period compared to control groups. The
study periods ranged from 12 weeks to several years, and the
settings were at home, in clinic, or at school. The comprehensive
treatment models or adapted versions of them were used either
alone or in combinations in these RCTs as described below.
Psychosocial Interventions
Early Intensive Behavioral and
Developmental Interventions
1. UCLA/Lovaas-based Model.
This intensive and manual-
ized intervention primarily utilizes techniques derived from
applied behavior analysis, which is administered on a one-
to-one basis for many hours per week. A therapist and a
child will work on practicing specific social skills, language
usage, and other target play skills, with reinforcement and
rewards provided for accomplishments and mastery of skills.
2. Early Start Denver Model (ESDM)
Interventions are
administered in naturalistic settings such as in day care, at
home, and during play with other children. Parents are typi-
cally taught to be co-therapists and provide the training at
home while educational settings also provide the interven-
tions. The focus of the interventions is on developing basic
play skills and relationship skills, and applied behavior anal-
ysis techniques are integrated into the interventions. This
approach is focused on training for very young children and
is applied within the context of the child’s daily routine.
3. Parent Training Approaches
This includes Pivotal
Response Training, in which parents are taught to facilitate
social and communication development within the home
and during activities by targeting gateway or pivotal social
behaviors for mastery by the child with the expectation that
once these central social skills were mastered, a natural gen-
eralizing of social behaviors would follow. Extensive parent
and family components are integrated into this type of inter-
vention. Other parent training approaches focus on language
