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August 7, 2022
"I suggest helping families develop an "I can do approach" to help their child build some measure of independence by finding out what the child can do and adding on to it sequentially. "
-- Charlyne Gelt, Ph.D., (PSY22909), M.F.T.

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The Many Faces of Autism

by Charlyne Gelt, Ph.D., (PSY22909), M.F.T.

Laurel entered her first day of middle school with a bang, literally. Feeling threatened and scared at the thought of anyone getting too close to her, she exploded when a schoolmate opened his nearby locker. She hit him over the head with a thousand- page book on Winston Churchill that she carried around for leisure reading. As the paramedics rushed her unconscious locker partner to the emergency room, Laurel was escorted to the vice principal's office for what was sure to be a severe reprimand.

Instead, the vice principal sat in stunned amazement at the wealth of knowledge Laurel displayed about Churchill, a subject he had studied for years. A strong academic bond was established between them; Laurel had found her "rhythm of safety." She is one of the lucky ones.

Laurel is autistic, and like so many other autistic children, she feels lonely and isolated in an often unfriendly world.

Autism falls under the umbrella of Pervasive Developmental Disorders. Other diagnoses in this category are Rhett's Disorder, Childhood Disintegrative Disorder, Asperger's Disorder and Pervasive Developmental Disorder Not Otherwise Specified.

These disorders are usually evident in the first years of life and are characterized by a wide range of cognitive manifestations, from non-verbal with severe mental retardation and self-injury to above-average IQ with impaired language and inadequate social skills.

Sometimes the symptoms are so mild the child can almost "pass" as normal. In other cases, symptoms can be severe enough that the child requires institutionalization.

Autism impairments appear primarily in three behavioral domains: social interaction; communication and imaginative play; and markedly restricted range of interests and activities.

The Autism Society of America estimates that every day 50 children in the United States are diagnosed with a form of autism. The rate of children being diagnosed with autism is now as high as one in 166. Ten years ago it was one in 2,500. One out of every 250 babies born today will develop some form of autism. It affects five boys to every girl and is the third most common developmental disability following mental retardation and cerebral palsy. It knows no racial, ethnic or social boundaries.

The skyrocketing numbers challenge society's ability to treat these children and the demand for services is rapidly outpacing the supply of specialized providers. The United States spends $90 billion a year to provide care for the country's 1.5 million autistic children and adults and it's estimated that cost could balloon to $200-$400 billion by 2013.

When faced with a child's diagnosis of autism, parents often experience denial, grief and helplessness for their child who seems to live in a world they know nothing about. Family dynamics are forever changed by this challenge.

I know such children well, having worked with them for many years both as a special education teacher and as a licensed marriage and family therapist. As a special education teacher with a day class of autistic students, I prepared these children to be mainstreamed into the regular classroom academically, behaviorally and emotionally.

I developed a variety of behavioral management interventions and created hundreds of Individualized Education Plans (IEPs). Later, as a licensed MFT, I expanded my focus and worked therapeutically with families devastated by their child's disorder.

Eight-year-old Alan entered my office with his mother flapping his arms against his sides, spinning in circles and buzzing like an airplane. He evidenced symptoms such as repetitive behavior, self-stimulation and self-absorption. He was unconcerned that his mother was present and ignored her. His eyes never met hers or mine and never left the floor. After his mother introduced Alan to me, he buzzed out my name like a song but without variance in volume or pitch, then went back to buzzing, spinning and flapping.

After several sessions during which he stared out the window, it was clear he was quite observant, not of people, but of birds and other things that flew in the sky. The buzzing and spinning were his attempts to fly. As I observed him outside in his natural environment, I learned he would sing like birds and that was his way of communicating. He could mimic behavior; it just wasn't human behavior! Because Alan could function at a primitive level, that's where I began his therapy.

The story of 11-year-old Janice is a little different. She was diagnosed with Asperger's Disorder which is at the highest- functioning end of the autism spectrum. Although no one in her family displayed any musical talent, Janice could memorize musical scores after hearing them just one time, often at a concert. All the way home she practiced the score in her mind and could play the piece from memory once she sat down at the piano.

Janice presented with a mix of abilities. While she could tell you the day your birthday would fall in any given year in the future, if you asked her the current time of day, she'd stammer, stutter and break out in a rash. She had no close friends and little interest in making friends. In fact, she would go out of her way to avoid others.

It is clear from these case studies there is a wide variation in behavior for children who have been diagnosed in the autism spectrum. The challenge is formulating effective treatment plans given such diversity.

In my experience, an eclectic, humane and multi-modal approach is most effective. The goal is to tailor services to each child's unique set of needs since there is no proven "relationship between any particular intervention and children's progress," according to the National Academy of Sciences.

Historically there have been two main approaches to treating autism, the disease model and the behavioral model.

According to the disease model, autism is an illness and the child's behaviors are symptoms of the illness. Treatment is focused on removing the disease (autism) which then would remediate the autistic behaviors. The behaviors themselves are not specifically targeted for intervention, as they are considered symptomatic.

The behavioral model breaks autism down into small conceptual units (self-destruction, imitation, vocalizations, units of grammar, labeling, etc.). A system of rewards is used for learned behaviors, such as brushing teeth or sitting properly at a table. The behavioral approach also focuses on educational outcomes and is measured by performance-based tests. Behavioral interventions are concrete and can be very effective in helping clients achieve simple attainable goals.

The use of medications or a cocktail of medications (anti-psychotics, tranquilizers, anti-depressants) can be useful if there are co-morbid attention problems, depression, or obsessive-compulsive behaviors that would negatively impact treatment outcome.

Clearly, the multiple "faces" of autism require multiple treatment strategies, including supportive family therapy. I suggest helping families develop an "I can do approach" to help their child build some measure of independence by finding out what the child can do and adding on to it sequentially.