The Adam “Rating Scale”

Filed Under (Autism and Intelligence, Autism and Learning, Autism Spectrum and Diagnosis, Behaviours, Communication, Development) by Estee on 16-04-2012

I’m in the process of completing forms. Adam was diagnosed with autism at eighteen months of age. Now that he’s ten, I’ve been re-reading files and reports from clinicians and teachers over the years. We’ve never had a formal IEP because he’s not in public school. Instead, I’m creating a comprehensive history of Adam. I’m also making it current, adding samples of his work along with new reports. I’m calling it Adam’s Ability Binder. It not only will list Adam’s challenges, but will focus more on his abilities as a means to serving him well. Ideally, it will address his ability and disparity of skills — where he is advanced and where his disability makes life more challenging. When it is done, I’m going to find a way to ask Adam what he likes the most and add that to the binder. Right now, I’m combing through years of typed conversations to include and add to this list.

My intention is that it becomes Adam’s living document that goes with him, and to which he can contribute as he grows older. We have no system which understands autism comprehensively, let alone the nuance of every autistic individual. I am trying to create that for Adam and I’m trying to work within the system we have.

I’ve been going through these “Autism Rating Scales” again. They took me three hours to complete. In some of the line I couldn’t stop myself from writing “that is a silly question.” Or “this is a biased question,” when refering to whether my child does “strange things.” I don’t think the things Adam does are “strange.” I know him to be a normal autistic person, for lack of better terminology.

Here were but some of my pet peeves about the questions:

How can we tell if a child is “laughing inappropriately” if they cannot tell us why they are laughing? Laughing and giggling can also be a sign of stress. What if a child’s autism doesn’t let them respond consistently? Adam can sometimes draw with great focus and other times he can barely seem to hold a crayon. Sometimes he speaks full sentences and other times he can’t utter a word. Talking about “shared interests” comes with great patience from a skilled communication partner, and Adam may reveal it verbally or typing, but not yet all of the time.

When completing the Vineland-II, BASC-2, GARS-2, ARS, or Conners 3, it’s so easy for me to notice what’s missing from these “scales.” I sigh and mumble through them, and realize I’ve got my own summaries to add. Many of the questions are also about friends. Adam seems aware of his difference, and I’ve learned this when he has typed about it. I also know Adam to avoid situations where he is aware of his difference or think he might fail. I’ve seen Adam approach a group of children to join in, then stops and waits on the sidelines because he doesn’t know how to “get in.” Recently when another child expressed pity towards him because he is autistic, Adam stopped jumping and smiling. After standing on the periphery of children, not sure of how to join them, he gives up and goes back to playing on his own. Sometimes he doesn’t know the rules of the game and can’t play when he is invited. Is this “not interested in other children?” Of course it isn’t. His inability to communicate like others, however, and in keeping up with the rapid rhythm of activity and conversation makes having friends challenging. Still, Adam has made leaps this year — wanting to join in with other children, and his increase in spoken language.

Thankfully the person evaluating Adam has recognized the limitations of these scales and the complexity of him. It is important to have your assessors understand this and urge them to observe in every setting possible. It’s important to know what lens we are assessing the autistic child through. Some of them can distort the image.

Now my back hurts from sitting at my desk too long. I’ll be back at it tomorrow, hoping to tip the scales in a fair direction.

Autistic Wandering and the DSM

Filed Under (Activism, autism, Autism Spectrum and Diagnosis, Discrimination) by Estee on 04-04-2011

Recently, the CDC proposed a separate criteria for wandering in autism. You can find the PDF here. I have received permission from the Autism National Committee (AUTCOM) to make this letter available to readers in response to the proposal:

Dear Ms. Pickett:

We are writing as a coalition of organizations representing a wide variety of different constituents in the disabilities field. We include organizations run by people with disabilities as well as those run by parents, other family members, professionals, providers and many others. Our coalition also includes groups representing a wide array of different kinds of disability categories, including developmental disabilities, mental health conditions, physical disabilities and sensory disabilities. We are writing to express our profound concern about the proposed ICD-9-CM code for wandering discussed at the last meeting of the ICD Coordination and Maintenance Committee on March 9th-10th.

While wandering behavior leading to injury and death represents an important and legitimate safety issue for the disability community, we are concerned that the proposal put forward by CDC’s National Center for Birth Defects and Developmental Disabilities (NCBDDD) is not rooted in high quality research and has significant potential unintended consequences for people with disabilities and family members. We encourage the National Center for Health Statistics to reject an ICD-9-CM coding for wandering behavior as ill-advised and inappropriate.

First, a code for wandering behavior could limit the self-determination rights of adults with disabilities. The wandering coding has no clear operational definition and thus no limits to its application. The proposal makes no distinction between wandering behavior that would qualify for the coding and a rational and willful effort by an individual with a disability to remove oneself from a dangerous or uncomfortable situation. For individuals with significant communication challenges, attempting to leave a situation may be one of the only ways of communicating abuse, a sensorily overwhelming situation or simple boredom. We are concerned that if this coding enters the ICD-9-CM such attempts at communication will be disregarded as medical symptoms.

Second, a code for wandering behavior could lead to serious unintended consequences in professional practice for schools and residential service-provision settings for adults with disabilities. Restraint and seclusion in schools and in residential service-provision settings is already a persistent problem. The application of this coding may result in increased restraint and seclusion as a way of preventing wandering behavior, supplanting required active support, person-centered planning and appropriate supervision. In addition, we are concerned that this coding may enable other forms of overly restrictive interventions and settings. For example, individuals with disabilities who are labeled with a wandering coding may be less likely to be included in the general education classroom, more likely to be placed in large group homes or institutions and more likely to experience chemical restraint. Each of these issues already represents a critical problem for people with intellectual and developmental disabilities that this coding may exacerbate. For example, while only 18% of adults on the autism spectrum receiving developmental disability services have a diagnosis of mental illness, 41% of such individuals are receiving psychotropic medications, suggesting a high incidence of chemical restraint.

Third, the proposed ICD-9-CM code for wandering behavior lacks research support and is not based on evidence or a controlled examination of the issues involved. No research exists to look at wandering as a medical rather than behavioral issue. The research which CDC relies on to make the case for this coding is weak. For example, one of the statistics that CDC cites (that 92% of families of children on the autism spectrum report at least one or more incidents of wandering) comes not from a high quality research study, but instead from an online poll on the website of an advocacy organization. This is not in line with the high standards for research and evidence that CDC’s bases its other decision-making on.

While we respect the good intentions behind the creation of this coding, we firmly believe that there are other ways of accomplishing the positive objectives of this coding without placing people with disabilities and our families at risk of the same unintended consequences. Other methods of data collection around wandering can and are being pursued by both public and private funders. In addition, a wide variety of human services and educational approaches hold significant promise in addressing the issue of dangerous wandering behavior outside of a medical context. As a result, we strongly urge you to reconsider and reject the proposed ICD-9-CM coding for wandering behavior.

Regards,
Autistic Self Advocacy Network
Council of Parent Attorneys and Advocates (COPAA)
National Association of State Directors of Developmental Disability Services (NASDDDS)
TASH

If you wish to respond, please contact AUTCOM or circulate this letter.

Adam, The Autistic Self-Advocate

Filed Under (Acceptance, Advocacy, Autism Spectrum and Diagnosis, Autistic Self Advocacy, Communication) by Estee on 18-10-2010

“Turn it off!” I had been watching some old videos of Adam before he was even two years old. Adam, now eight-years-old, stood in front of the television and watched for two minutes intensely before he told me what to do.

There are two therapists in that video, in front of him talking fast and loud. He is sitting in a chair and they insist that he stay there — he small enough that every time he tries to escape they physically replace him onto the chair. The video begins with Adam crying, squirming and trying to get away. He is so small, such a baby. He is saying many things, although they are hard to hear because the therapists are talking so loudly compared to his forming, warbled articulation. As one of the therapists replaces his tiny body in the chair, she tickles his stomach.

“Don’t,” I hear him say in a super tiny voice. I hear him say it now re-watching these, but I may not have heard it back then. I may have not heard it in the frantic effort to get Adam to do and say what the therapists wanted him to say. I would have not heard it over their loud voices.

I am watching these videos six years later, as Adam has developed and changed so much. I feel we have very much entered a new phase of life together, a new phase of understanding our lives as an autistic family.

Adam then went to his Vanguard device after telling me to shut off the TV. “I am uncomfortable,” he pressed. I suppose I can say, said. We call it his talk box. The Vanguard device, which is a series of pictures and words can be programmed to make sentences. Things like verbs, feelings, activities are all categorized on it so Adam can tell us many things. Sometimes Adam can type sentences on his computer, sometimes he uses the Vanguard and sometimes, especially this past weekend, Adam can talk. Adam talked more this past weekend than I can remember in his lifetime.

I have set out to watch those videos on my own without Adam present. As I watch them now, I am highly disturbed. We made him sit so young, and forced him to watch the therapists. Although this was NOT a strict ABA program, we did attempt to “programme” Adam in an ABA format. The therapists talked, they wanted him to answer, they dangled coloured circles over his head so he would repeat the colours, blew in his face, repositioned him on the chair — all at a roaring rate. I cannot imagine how completely overwhelming that experience was for Adam.

All I had in the beginning was ABA therapy. Then came along RDI (Relationship Development Intervention). I thought I kept helping Adam better each time I learned about something new because no one offered us any other solution. While I tried to follow my instinct, what was available to us wasn’t keeping pace with the values I was forming about Adam as an autistic person. Still, Adam was forced to “conform” no matter how much we said it was to “engage” him. Later, we became more adept at involving ourselves in his games. Later, we became quieter with him.

As Adam’s mother, I sometimes want to cry when I watch these videos. He was bombarded. In no way was he respected as an autistic person from the get-go. A couple years after that I definitely learned more and tried harder. Yet I wonder, since we are still talking about finding genes in autism and intervening earlier, what kind of life experience our autistic children will have and remember, when they are programmed to be typical.

I find it so ironic that Adam talked the most he had in his lifetime this weekend, and he told me to turn off one of those “early intervention” videos. I suspect he does not feel good about it at all. What makes me feel so guilty, because I love Adam so much, is that even though I searched for ways of assisting him while trying to respect him, he may have not been in those earlier years when he was so vulnerable. He couldn’t really communicate in words then. He has severe difficulties, even now, to do so consistently. As Adam becomes his own self-advocate, I just found it so striking to have this juxtaposition between the old videos against the Adam of today. Even back then, just because he wasn’t talking, he was still a person. I suppose I could say he was ignored like the moment when he said in a voice so quiet, “don’t.”

I think if someone had shown me this when we received the diagnosis, if autistic people could recount their stories and be available to all “new” autism parents, my life may have been calmer and Adam may have had better supports that accepted him as autistic. I write this with forboding, wondering what kinds of early interventions are being concocted for infant autistics. Certainly, I changed the approaches after those first two years, and he became happier for it. He has had many challenges, but he is also now talking. As he does so, while it is nice to know what our children are thinking, I can tell you it is not a solution. It is not the Holy Grail. We will have many years ahead of dealing with Adam’s unique way of functioning in the world, and I don’t always expect it to be easy. Communication is important. Acceptance is vital.

Is Having A Disorder The New Normal?

Filed Under (Acceptance, Activism, Advocacy, autism, Autism Spectrum and Diagnosis, Book Reviews, Critical Disability Studies, Inclusion) by Estee on 28-07-2010

Using the title from Kat Kelland’s article in today’s Globe and Mail, she suggests that experts are worried that, with the extended array of defined disorders in the soon-to-be-released DSM V (Diagnostic and Statistical Manual), no normal person will continue to exist.

“Citing examples of new additions like ‘mild anxiety depression, ‘psychosis risk syndrome,’ and ‘temper dysregulation disorder’…many people previously seen as perfectly healthy could in future be told they are ill….’It’s leaking into normality. It is shrinking the pool of what is normal to a puddle…

Dr. Wykes and colleagues, Felicity Callard, also of Kings Institute of Psychiatry, and Nick Craddock of Cardiff University’s department of psychological medicine and neurology said many in the psychiatric community are worried that the further guidelines are expanded, the more likely it will become that nobody be classed as normal anymore.”

Well, it’s about time. Perhaps ironically, I’m not one for self-help aisles and a belief that we all suffer from some made-up ailment that can be remedied with expensive quackery. At the same time, I also understand that there is a widespread concern that if we simply dilute human differences and challenges we do not address serious  medical and practical needs. In other words, some people fear that a complete distillation of humankind will take away much needed work towards attaining the services, medical attention, and accommodations that we continue to need in order to replace the treacherous world of asylums. This article in The New York Times, cites some of the other concerns specific to the autism diagnostics proposed for the new manual.

What the Globe and Mail article assumes quite simply, however, is that there are only two kinds of people: normal and abnormal. We know that in history that it is this whitewash, this binary, that is the most dangerous because it has  subjugated individuals with differing needs, thinking ability and functioning levels to not only the margins of society, but to maltreatment and exclusion of all kinds.

Until  recently, disabled people have had no rights. Still today, seen as non-persons despite legislation and the ADA, disabled and autistic individuals continue to struggle for their right to have a voice at policy-making tables, and to be accepted and accommodated for their needs while contributing as autistic and disabled people. Not a day goes by that the notion of cures and getting “better” (that is “more normal”), underlies the purpose of teaching autistic people at all, as opposed to teaching them to their strengths and abilities as well as with a regard to the value of autistic contribution.

As a committe works to redefine the characteristics of autism, the questions that the committee ask in the panels are well worth reading.  I cannot help but wonder how getting an autism diagnosis may change for parents and autistic people, and consider that the future could be brighter. In my view, we seem to be asking some of the right questions with regard to the spectrum of autism and the fallacy of the association between intelligence and functioning levels. So I guess I’m saying that as I read the Globe article this morning, I was sort of nodding my head. Yes, there is no normal….that’s right. Why fear that? What is it that we must do and how must we think differently in order to finally obliterate that binary?

It is here that  I have to refer to Wendy Lawson’s book Concepts of Normality: The Autistic And Typical Spectrum (Jessica Kingsley Publishers, 2008). In it she states,

“Currently the debate about ‘what is normal’ is causing some heated exchange; this is not new. In particular the debate concerning autism, disability, neuro-diversity and typicality poses some ongoing challenges. Disability presents itself in a variety of ways, and for most of us living with disability, who we are is normal for us. For many people on the autism spectrum, which is certainly very disability in a world that does not accept, value or accomodate ‘difference,’ being handicapped is an everyday reality…Having a respectful understanding of one another should include accessibility to appropriate resources, support, safe places and sincere appreciation of difference. Anything less is not acceptable.” (Introduction)

Recently, Thomas Armstrong released his book, Neurodiversity: Discovering the Extraordinary Gifts of Autism, ADHD, Dyslexia and Other Brain Differences, (De Capo Press, Cambridge, 2010). In his first chapter “Neurodiversity: A Concept Whose Time Has Come,” he has cleverly quoted Margaret Mead:

“If we are to achieve a richer culture, rich in contrasting values, we must recognize the whole gamut of human potentialities, and so eave a less arbitrary social fabric, one in which each human gift will fall into place.” (from Sex and Temperment in Three Primitive Societies).

Thomas goes on: “In 1952 the first edition of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association listed one hundred categories of psychiatric illness. By 2000 this number has tripled. We’ve become accustomed as a culture to the idea that significant segments of the population are afflicted with neurologically based disorders such as ‘learning disabilities,’ ‘attention deficit hyperactivity disorder,’ and ‘Aspergers syndrome,’ conditions that were unheard of sixty years ago. Now, even newer disabilities are being considered for the next DSM in 2010, including relational disorder, sexual behaviour disorders, and video game addiction.”

“How did we get here?” Thomas asks. He cites things like a greater knowledge of the human brain and research into the area, a growth of advocacy movements that push for “awareness,” (alas, is it no wonder why most of us shudder at “Autism Awareness Month?). Mostly, the need for the advocacy marketing plan is the way to raise money for things like remedies and therapies. No family wishes to envision their children in asylums and mental hospitals (another topic because they were set up with all of the good intentions we have today for many of our “centres,” but ended up so overpopulated that the patients within them were neglected and abused). While there has been a valid reason for advocacy movements, perhaps an acknowledgement that all humans are interdependent and need different supports (no matter the severity of their handicaps), may be a very welcome change.

While we keep tripping over the question of what is normal, I wonder if we need a supplementary manual that cites abilities, suggestions for inclusion, education, and the like.  Perhpas we need not define handicaps as disorders, but very real challenges and acknowledge them against the social stigma of having any kind of disability. I have to question that if the stigma didn’t exist, would we also be a society that tends towards over-medicalization? For I do acknowledge that heading into a doctor’s office these days one wonders why so many meds are offered so readily for what I feel to be the way in which we respond to life — anti-depressants and meds like Ritalin come to mind.

To me, this need not be a question of what is the right or the wrong way to be human, but how to support all ways in which to be human. A DSM can only do so much. It is up to us to ensure that we cultivate the society that treats and regards each person individually, for although we are united in our lack of normality, we are also unique. It’s a complicated matter indeed, but in the end, all we wish is to be seen and loved…blemishes and all.

Diagnosis, Determinism and the DSM V

Filed Under (Autism and Learning, Autism Spectrum and Diagnosis) by Estee on 09-11-2009

I was sitting in a waiting room recently when I picked up this from the April 2009 issue of Today’s Parent magazine’s article, Is It A Learning Disability by Marcia Kaye. I turned the pages reading about “conceptual and motor problems,” and in the middle of the page was a photo of a drawing.

“They don’t draw, they scribble,” said the caption.

Who are they? I thought. Does she really know who she is referring to?

The they, is the Adam who when he made is first intentional scribble on the page, I jumped happily. Whose “motor problems,” and indeed they are challenges, in holding a pencil or a crayon seemed to be surpassed. At least the first step had been made. You see, I’ve kept every one of Adam’s “scribbles,” his effort rewarding by his marking that later turned to a happy face, a letter, a sun and a tree and one day, a happy face with long hair which he named “mommy,” at the age of six. The theyare people. They are Adam. They are individuals who are challenged but not unintelligent, who continue to progress at their own rate on the exterior, while on the inside, have many ideas and things to share.

And then there is the category of Non-Verbal Learning Disabilities, which I read with great interest. For the Today’s Parent article stated that “this category encompasses non-verbal learning disabilities (NLD’s), which is a controversial area, with possible overlap into Asperger’s syndrome and mental health issues. But the LDAC [Learning Disabilities Association of Canada] considers NLD to be a bona fide learning disability. A child with an NLD may have a great vocabulary, a good memory and an excellent grasp of detail, but miss the bigger picture. He may be a good reader, but a poor comprehender…if you say ‘Oh great, I have to get a root canal!’ they may take you seriously.” It goes on to describe the social awkwardness and anxiety issues that we so often talk about with regards to autism.”

And to to muddy the waters even a little bit more, we have the discussions over DSM V [Diagnostic Statistical Manual] and removing Aspergers or what differentiates individuals along the autism spectrum:

The Neurodevelopmental Disorders (ND) work group’s discussions have focused on three areas:

1) Possible modification of ADHD criteria to allow for co-morbidity of autism and ADHD (currently excluded). The ADHD & Disruptive Behavior Disorders Work Group has agreed to consider this possibility.

2) Discussion of the validity of Rett’s disorder as a separate disorder and inclusion of a new modifier within the Autism Spectrum Disorders (ASD), which might include genetic and medical disorders and other biologically-definable conditions.

3) How to address Pervasive Developmental Disorders – Not Otherwise Specified (PDD-NOS). The individuals currently diagnosed with PDD-NOS may still be described in DSM-V, but the work group will discuss whether they can redefine ASD in such a way that the PDD-NOS diagnosis isn’t necessary, as this diagnosis currently captures a very heterogeneous group of individuals.

The ND Work Group will be seeking additional feedback from advisors and other experts prior to “finalizing” any recommendations.

Questions still under active discussion for ASD include:

1) How to describe the “spectrum” of disorders now known as ASD (e.g., how many domains will define the disorder);

2) What is the specificity of repetitive behaviors in ASD and how might they be better defined;

3) Whether Childhood Disintegrative Disorder (CDD) is a unique and separate disorder, and if so, what are its defining characteristics;

4) Whether autism is a life-long diagnosis or whether it is possible to recover/remit to the point where the diagnosis is no longer applicable;

5) Whether Asperger’s disorder is the same as “high-functioning autism”;

6) How the DSM-V can alert clinicians to common medical comorbidities (including genetic disorders, epilepsy/EEG abnormalities and sleep, or GI problems) and potential biomarkers;

7) How to include consideration of severity and impairment in diagnosis (currently defined as “qualitative impairments”) and how to integrate these with the overall structure of DSM-V; and

8) How/where to discuss cultural influences on diagnosis (e.g., Korean use of reactive attachment disorder rather than ASD to avoid family stigmatization).

What is most poignant to me is the purpose of both the differentiation and the suggestion that the atypicalities are abnormal rather than a way of being in the world. If Adam’s way of obtaining and processing information about his environment and the people around him are respected (as they are in his household and school), then he continues to grow, mature and learn. And while there continues to be little research that truly helps us understand how “severity” has often to do more with outward “functioning” rather than intelligence, I struggle with articles that fail to discuss how society tends to want to categorize and differentiate individuals based on the severity of their learning disability rather than discussing how people with different or atypical learning needs learn and how we can better support them.

When I read the suggestions for broadening autism to emcompass Aspergers and other characteristics in the DSM V, the issue as I see it is not the damaging effects that calling Asperger’s or PDD-NOS or NLD to autism is to the person or family. For I view it as the families’ discomfort in perhaps being associated with autism. I see the issue is a continued determinism about autism and herein lies the problem. Until autism and many issues are no longer viewed as problems to be solved, but rather atypicalities that require our understanding and providing for, we will forever find ourselves spinning on the hamster’s wheel.

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About Me


ESTÉE KLAR

I’m a PhD candidate at York University, Critical Disability Studies, with a multi-disciplinary background in the arts as a curator and writer. I am the Founder of The Autism Acceptance Project (www.taaproject.com), and an enamoured mother of my only son who lives with the autism label. I like to write about our journey, critical issues regarding autism in the area of human rights, law, and social justice, as well as reflexive practices in (auto)ethnographic writing about autism.