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AUTISTIC DISORDER

At the time of his initial consult at a university – based clinic, Ritchie Firkins was a 5 – year – old Caucasian boy who had for 2 months been attending kindergarten, where he was in a special education class with children who had developmental delays (e.g., delays in intellectual, social, or verbal development) or emotional problems. Ritchie had been diagnosed with autistic disorder at the age of 2 ½. From the age of 2 years on, Ritchie had engaged in frequent temper tantrums, during which he screamed, banged his head, and hit others. When Ritchie started attending kindergarten, however, the frequency and severity of his tantrums increased markedly, both at school and at home. Every day, Ritchie typically had five tantrums at home and six tantrums at school. In addition, Ritchie refused to sit at his desk at school for more than a few minutes. He often ran around the classroom, and he rarely paid attention to the teacher.
During in school meeting, Ritchie’s teacher and parents agreed that they were all having a great deal of difficulty managing Ritchie’s behavior problems and that these problems were getting worse. Ritchie’s parents believed that the increased structure and the higher expectations for good behavior in a kindergarten classroom were the likely reasons for their son’s increased tantrum problems. Ritchie’s tantrum produced considerable disruption at home. For instance, because of the tantrums, the family had canceled a vacation and had gone on fewer local outings to such places as zoos and museums. When Ritchie’s parents went on outings, such as dining out, attending a movie, or shopping, they frequently left Ritchie at home with a babysitter (to ensure that others were not exposed to their son’s behavior). At the end of the school meeting, Rotchie’s mother agreed to call the local university in order to reach someone who could assist both her and Ritchie’s teacher in managing his behavior problems.

Clinical history

The first sign of Ritchie’s autistic disorder appeared when he was 2 years old. At that time, Ritchie’s parents noticed that he was quite withdrawn and that he did not demonstrate an interest in or preference for being with his parents or his older brother (who was 4 years older than Ritchie). For example, Ritchie’s parents observed that, unlike their older son, Ritchie did not appear to enjoy being held. He often pulled away when they tried to hug him, and he rarely sought them out when he was distressed.
From that time forward, Ritchie’s parents noted that their son did not appear interested in other children, including his older brother. Over his entire 5 years of life, Ritchie never had any friends. In addition to his lack of interest in others, his peer did not seem to enjoy being around Ritchie. Several of his kindergarten classmates had demonstrated jealousy toward Ritchie because he was the only child in the class who could easily get away with not sitting still and not paying attention to the teacher. Also, some children feared Ritchie because of his frequent tantrums. In addition to his lack of interest in others, Ritchie had never developed an interest in doing things independently, such as dressing or cleaning himself. If his parents insisted that he do something (such as brush his hair), Ritchie usually responded by having a tantrum.
Ritchie had also demonstrated a severe language delay; in fact, he had not developed any speech whatsoever. Occasionally, Ritchie had been able to communicate with his parents by taking one of their hands and placing it on an object that he wanted. For example, it Ritchie wanted to watch television, he would take his father’s hand and guide it to the TV remote control. Most often, however, Ritchie wanted something, such as milk that was out of his reach, he would often scream or bang his head against something. His parents typically responded by looking around to find what Ritchie wanted so that they could give it to him and he would stop his tantrum.
In addition, Ritchie’s had engaged in repetitive and ritualistic behaviors. From an early age, he had spent much time rocking back and forth and flapping his hands. Also he frequently spun objects, such as toy cars, pens, and pencils. Ritchie’s parents reported that they had never seen him play with toys appropriately.
Particularly problematic were Ritchie’s ritualistic behavior and intense desire for things to stay unchanged. Ritchie had previously been diagnosed by the school psychologist as having attention deficit hyperactivity disorder (ADHD), a disorder characterized by a persistent pattern of inattention, hyperactivity – impulsivity, or both, that is clearly more frequent and severe than would be expected for the person’s age. As is often the case, Ritchie was not diagnosed with ADHD until he began kindergarten. There were few demands for Ritchie to sit still and pay attention at home and at preschool. In kindergarten, however, Ritchie was expected to sit for long periods several times a day. For instance, Ritchie was expected to sit still for morning a circle and he was expected to pay attention while his teacher read the class a story each afternoon. As noted earlier, Ritchie did not meet these expectations. He typically ran around the room while the other children paid attention to the teacher. Prior to Ritchie’s first visit to the university clinic, the family doctor had prescribed methylphenidate (Ritalin) as a treatment for Ritchie’s ADHD symptoms. The Ritalin had seemed to have some benefit because the teacher believed that Ritchie’s inattention and hyperactivity had decreased since he began taking the medication.
Ritchie came from an affluent family. His father was a biochemist and his mother was an accountant who owned and ran a successful accounting firm. As is virtually always the case with autistic disorder, no significant stressors or other environmental factors were evident that could be linked to the origins of Ritchie’s problems. Throughout his entire life, Ritchie had been in excellent physical health and never had any known medical problems. He had been raised in a very supportive and loving family. He attended an excellent school that had many resources. Ritchie’s family did not have a history of developmental disabilities or emotional disorders. Ritchie’s older brother was quite well adjusted and doing very well in school.

DSM- IV Diagnosis

Based on this information, Ritchie was assigned the following DSM-IV diagnosis :
Axis I 299.00 Autistic disorder (principal diagnosis)
Axis II 318.0 moderate mental retardation
Axis III None
Axis IV None
Axis V Global assessment of functioning = 25 (current)

In DSM-IV (American Psychiatric Association, 1994), autistic disorder resides in a section entitled “pervasive developmental disorders”. Pervasive developmental disorders are characterized by severe and wide-ranging impairment in several areas of development, including social interaction and communication skills, and the presence of stereotyped behavior, interest, and activities. Although children vary in their rate of development, the impairments that define the pervasive developmental disorder are clearly deviant relative to the afflicted child’s developmental level or mental age. All pervasive developmental disorders are usually evident in the first 5 years of life, and each is often associated with some degree of mental retardation. In addition to autistic disorder, other types of DSM-IV pervasive developmental disorders include Rett’s disorder, childhood disintegrative disorder, and Asperger’s disorder (described and differentiated later.
As in the case with the other pervasive developmental disorders, autistic disorder is defined by the presence of markedly abnormal or impaired development in social interaction and communication and a markedly restricted repertoire of activity and interests. Accordingly, the key DSM-IV criteria for autistic disorder are organized into these three symptom areas: (a) impairment in social interaction; (b) impairment in communication; and (c) restricted, repetitive, and stereotyped patterns of behavior, interests, and activities. Each of these three key features is broken down into four specific symptoms. The symptoms of impairment in social interaction are (a) marked impairment in the use of multiple nonverbal behaviors (e.g., eye contact, facial expression); (b) failure to develop peer relationships appropriate to the child’s developmental level; (c) a lack of spontaneous seeking to share enjoyment, interests, and achievement with other people; and (d) a lack of social or emotional reciprocity (e.g., not actively participating in simple social play or games). The symptoms of impairment in communication are (a) delay in, or total lack of, the development of spoken language; (b) in children with speech, marked impairment in the ability to initiate or maintain a conversation with other; (c) stereotyped and repetitive use of language or idiosyncratic language (e.g., repeating jingles or commercials); and (d) lack of varied, spontaneous make-believe play or lack of social imitative play appropriate to developmental level (e.g., absence of playing games such as “Cowboys and Indians” or pretending to be a superhero). The symptoms of restricted, repetitive, and stereotyped patterns of behavior, interests, and activities are (a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus (e.g., persistently amassing baseball statistics at the expense of being involved in anything else); (c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, body rocking); and (d) persistent preoccupation with parts of objects (e.g., emotional attachment to a peace of string, fascination the movement of an electric fan or the spinning wheel of a toy). The DSM-IV diagnosis of autistic disorder requires the presence of at least 6 of the aforementioned 12 symptoms, with clear evidence of at least 2 symptoms of social impairment, 1 symptom of communication impairment, and 1 symptom of restricted repertoire of activity and interests. Moreover, to meet the definition of autistic disorder, delays or abnormal functioning should be evident in at least one of these three main symptom areas prior to the child’s third birthday.
Asperger’s disorder, childhood disintegrative disorder, and Rett’s disorder are comprised of symptoms that are quite similar and often identical to the symptoms of autistic disorder. For instance, like autistic disorder, Asperger’s disorder is also characterized by impairments in social relationships and restricted or unusual behaviors. However delays in language skills are not present in Asperger’s disorder, leading some researchers to conclude that this condition is simply a milder from of autistic disorder. Childhood disintegrative disorder consists of the same symptoms as those found in autistic disorder but is differentiated by a severe developmental regression (in language, adaptive behavior, and motor skills) after a period of normal development over the first 2 to 4 years of the child’s life. Like childhood disintegrative disorder patients, children who develop Rett’s disorder also show normal development in the first several months of life. However, beginning some point after the fifth month of life, evidence of a progressive neurological disorder emerges, characterized by constant hand wringing, mental retardation, and impaired motor skills. Curiously, unlike the other pervasive developmental disorders, Rett’s disorder occurs almost exclusively in females.
Autistic disorder is discussed in more detail throughout the remainder of this chapter. You will note that, although Ritchie and been diagnosed by the school psychologist as having attention deficit hyperactivity disorder (ADHD), this diagnosis was not assigned by psychologists at the university-based clinic. Despite Ritchie’s ADHD symptoms, the DSM-IV criteria for ADHD specify that this diagnosis should not be given if the symptoms occur exclusively during the course of a pervasive developmental disorder such as autistic disorder (based on the notion that symptoms of inattention and hyperactivity are better construed as associated features of the pervasive developmental disorder rather than signs of a separate condition). This way true for Ritchie, and hence he was not diagnosed with ADHD.

Case formulation Using The Integrative Model

Like all of the other disorders discussed in this book, the working model of autistic disorder concludes that this problem cannot be attributed to a single cause. However, as noted by Barlow and Durand (1999), research on autistic disorder is in its infancy, and this area still awaits an integrative theory. Currently, very few researchers believe that psychological or social influences play a major role in the origins of autistic disorder (although, as discussed later, psychological and social factors may contribute strongly to associated features and the course of the disorder). The conclusion that social factors do not cause autistic disorder comes as a great relief to many parents of children with this condition. Early prominent theories (e.g., Bettelheim, 1967; Ferste, 1961; Tinbergen & Tinbergen, 1972) asserted that autistic disorder arises from other parents on various measures of personality and adjustment (Koegel, Schriebman, O’Neill, & Burke, 1983; McAdoo & DeMyer, 1978). In Ritchie’s case, there was clearly no evidence that parenting or other social factors contributed to the onset of his disorder.
The available evidence suggests that biological factors are associated with autistic disorder. Autism has a clear genetic component (Smalley, 1991). Although the sample sizes have been quite small (due largely to the rarity of autistic disorder), twins studies have routinely found higher rates of concordance for autistic disorder in monozygotic twins than in dizygotic twins (e.g., Folstein & Rutter, 1977; Steffenburg et al., 1989). For instance, a study of 21 twins pairs by Steffenburg et al. (1989) found that if one twin had an autistic disorder, there was a 91% chance that a monozygotic (identical) twin had autism as well, which is substantially higher than the rate of autistic disorder in dizygotic (Fratenal) twins; in fact, the concordance rate for autism in dizygotic twins was 0 (i.e.,in all of the dizygotic twin pairs, only one twin had autistic disorder). Because monozygotic twins have exactly the same genes whereas dizygotic twins only about 50% of each other’s genes (the same percentage shared among first-order relatives), the markedly higher rate of autistic disorder in monozygotic twin pairs suggests that genetic factors have a strong contribution to the development of autism. However, researchers have not identified a gene or genes responsible for this condition. Investigators do concur that the genetics of autism are not straightforward and several genes are likely to contribute to the disorder.
Neurological factors have been linked rather strongly to autistic disorder. Indirect evidence of a neurological component comes from the clinical observation that roughly 75% of persons with autism have some degree of mental retardation. Moreover, and appreciable proportion of individual with autistic disorder show some other form of neurological abnormality, such as clumsiness or abnormal posture or gait (Tsai & Ghaziuddin, 1992). Further evidence of neurological dysfunction comes from studies involving the use of computerized axial tomography (CAT) and magnetic resonance imaging (MRI), procedure used to generate pictures of a living person’s brain. Investigators using these imaging procedure have observed abnormalities in the brains of persons with autistic disorder, namely, the some people with autism have abnormally small cerebellums (the cerebellum is located in the hind brain, the lowest portion of the brain stamp, and is known to be involved in the control of motor coordination). Although this abnormality has not been observed in every person who has the disorder, it does appear to be one of the more consistent findings in autism research thus far (Cf.Courchesne, 1991). The fact that all person with autism do not have reduced cerebellum size reinforces the idea that autistic disorder has multiple causes (in fact recent preliminary studies using MRI techniques have found that many persons with autism evidence larger overall brain volume than those without the condition; e.g., Piven et al., 1995).
Even though genetic and neurological factors appear to play prominent roles in the origins of autistic disorder psychological and social factors nevertheless may have important contributions to the course and complications of the condition. One such factor is social reinforcement, a principle emanating from learning theory (Skinner, 1971). Reinforcement is discussed in detail in the next section in the context of Ritchie’s treatment planning.

Treatment goals and Planning

Although Ritchie displayed problems in many areas, this parents and teachers had the most difficulty coping with his behavior problems. Of greatest concern was the fact that Ritchie often banged his head on the floor during these tantrums. On several occasions, these behavior had resulted in large bumps on his head. In same tantrums, Ritchie screamed loudly or hit others. Therefore, his parents requested assistance in reducing Ritchie’s tantrums. Interestingly, despite Ritchie’s diagnosis of autistic disorder nearly three year before, he had not received any professional intervention prior to his visit university-based treatment clinic (although Ritchie’s mother had been very active in learning about autism, having attended many workshop and read several books on the topic).
Ritchie’s therapists believed that, although his autistic disorder was likely do way to a neurological abnormality, his behavior problems were being maintained by reinforcement. Reinforcement refers to environmental consequences for behavior that strength then it or increase its frequency. Children with autistic disorder appear to be at great risk for developing behavior problems (such as tantrums) because they are unable to communicate by speaking. These children often learn to receive things by engaging in their problem behaviors. As discussed earlier, Ritchie seemed to have learned to communicate by throwing tantrums. If he wanted milk that was out of reach, he would scream and bang his head. Like most parents, Ritchie’s parents would become distressed at the sight of their son crying or hurting himself. Thus, they responded by quickly giving Ritchie the milk (or whatever else he wanted) to stop his tantrum. However, while offering the milk was successful in ending the tantrums, Ritchie’s parents where reinforcing their son’s behavior problems and well making these behaviors more likely to recur. In essence, Ritchie learned that he could promptly receive what he wanted by throwing a tantrum (i.e., the positive consequence of getting milk reinforced the behavior of having a tantrum). In addition, children with autistic disorder often learn to avoid things by engaging in problem behaviors. For instance, Ritchie could get out of doing work by throwing a tantrum. Ritchie often cried when his father asked him to brush his hair or learn some other grooming skill. Typically his father responded to the tantrum by telling Ritchie that it was all right and that they could work on it latter in addition to his parents Ritchie’s teacher also seemed to be reinforcing some his problem behaviors. For instance, the teacher allowed Ritchie to get out of doing work (like sitting still during the reading hour) or gave him what he wanted whenever Ritchie threw a tantrum. Hence, the goals of treatment where (a) to teach Ritchie how to communicative in more adaptive ways so that he did not throw tantrums to communicate his needs and (b) to teach Ritchie’s parents and teachers how to respond to Ritchie’s problem behaviors in a fashion that would not reinforce them. To achieve these goals, Ritchie’s therapists intervened with functional communication training (Durand, 1990), a treatment that is discussed in some detail in the next section.

Course Of Treatment And Treatment Outcome

In total, 15 treatment sessions were held over a 6 – month period. Nine of these sessions were held at Ritchie’s school, and six sessions took place in Ritchie’s home. The first objective of treatment was to identify the things that were maintaining or reinforcing Ritchie’s tantrums. Ritchie’s therapists obtained this information by interviewing his parents and teachers and by observing Ritchie at home and at school. Consistent with the therapists’ impression from the initial meeting, it became obvious that Ritchie displayed behavior problems in order to get what he wanted and to avoid work. More specifically, Ritchie threw a tantrum when he food, when he wanted someone to restore his environment in particular manner (e.g., lower the blinds in the living room), and when someone asked him to do a chore (such as grooming). Having identified the manners in which Ritchie was being reinforced for having tantrums, the next goal of functional communication training was to teach him new, more adaptive ways to gain access to these reinforcers (in Ritchie’s case, food, assistance in arranging his environment, and escape from work).
The next step of treatment was to teach Ritchie to request the reinforcers that were maintaining his behavior problems. The therapists had to decide on the best from of communication for Ritchie. Because Ritchie had never developed any speech, the therapists decide not to try to teach Ritchie to communicate vocally. Instead, they decided to teach Ritchie to point to pictures of the things he wanted. Accordingly, A “communication book” was assembled that contained picture of the food. After he touched the picture, he quickly received something to eat. Over time, the therapists (as well as the parents and teachers) gradually reduced their prompts for Ritchie to touch pictures until he learned to independently touch the picture of food in order to receive something to eat.
After Ritchie learned to touch pictures to communicate his desire for food, the therapists added new pictures to the communication book. One of these pictures said, “Fix it, please.” This aspect of treatment began by raising the blinds in Ritchie’s living room and prompting Ritchie to touch the new picture. After Ritchie touching the pictures, the blind were quickly lowered. Using such strategies, Ritchie learned to independently request to have his environment rearranged by touching the appropriate picture. Later, another picture was added to book that said, “Break, please.” The therapists used the picture to teach Ritchie that he could receive a break from work by touching this picture. The instructions that the therapists provided to Ritchie’s parents and teachers for this aspect of treatment are presented in Table 16.1.
One of the most significant points of Ritchie’s treatment was the first time that he independently requested food with his communication book. Ritchie had never communicated in such a manner before and was, for the first time, able to request what he wanted without engaging in problem behaviors. Conceptually, the reason for this positive outcome is learning theory principle referred to as functional equivalence. That is, both Ritchie’s tantrums and his new communicative activities served the same function for him – obtaining food. With two functionally equivalent methods of acquiring food – throwing tantrums or pointing to pictures – Ritchie most frequently chose the response that presumably was easier for him; pointing to pictures.
It took Ritchie roughly 2 weeks of daily training (carried out by his parents and teachers after the therapists introduced the technique) to learn to use his communication book to request food. However, once Ritchie learned the benefits of using the book, he seemed more motivated to learn new responses. For instance, Ritchie learned to use his second and third phrases (“Fix it, please,” and “Break, please”) in about 1 week.
Nevertheless, Ritchie’s treatment did not proceed without complications. One came up shortly after Ritchie began to request food independently, at school he started asking for it a very high rate (approximately every 30 minutes). The teacher felt that it would be very difficult for her to offer Ritchie food his often. In response to this concern, the therapists decided to teach Ritchie to tolerate a delay in reinforcement. Initially, the teacher was instructed to provide Ritchie a snack immediately after he requested food. After 2 weeks had passed, the teacher was told to respond to Ritchie’s request by saying, “Yes, you can have something to eat, but please wait 2 minutes.” After 2 minutes had elapsed, the teacher gave Ritchie a snack. Three days later, the teacher added another 2 minutes to the length of time that Ritchie had to wait before he received food. Over the next several weeks, the delay for reinforcement was increased further (on average, she added 2 minutes every 3 days).
Some of Ritchie’s tantrums reappeared during the first week of delay of reinforcement. The teacher was advised to be sure not to add more time to the delay than Ritchie could tolerate. Although the teacher proceeded slowly, Ritchie’s tantrums indicated that the rate of increase in the delay was to great for him to hSandle. Thus, the teacher had to occasionally remain at a specific time delay of 30 minutes by displaying very infrequent tantrums. Once Ritchie could tolerate waiting 30 extra minutes to receive food (which translated into his receiving a small snack roughly once per hour), no more time was added to the delay. The teacher felt that offering Ritchie food at this rate was not disruptive to the class.
Another complication in Ritchie’s treatment was that the frequency of tantrums remained essentially unchanged in his music and gym classes. In other words, the use of the intervention had not generalized to other settings. In addition, Ritchie did not use his book with new teachers. Following these observations, all of Ritchie’s specialty teachers (i.e., music, gym, library, and art) were asked to attend a brief workshop to learn about functional communication training. These teachers also received hands – on training on how to prompt Ritchie to communicate with his picture book and how to fade these prompts. Following this training, the frequency of Ritchie’s tantrums remained low in all classrooms and with all teachers. In fact, Ritchie’s main teacher reported that, on a day when there was a substitute teacher in art class, Ritchie had indeed requested a break from work by using his communication book. Thus, these generalization training procedures were very important in Ritchie’s treatment because they helped him learning that he could use his book with a variety of people and in a variety of places.
After Ritchie’s behavior problem had been reduced to a level that his parents and teachers could tolerate, and after he was reliably using all three communication pictures in various situations, the formal treatment sessions were discontinued. Nonetheless, Ritchie’s parents and teachers were encouraged to contact the therapists if any further problems arose. By the end of treatment, Ritchie’s tantrums were infrequent. Most important, Ritchie no longer banged and injured his head, and his parents felt quite confident that his self-injurious behaviors were not likely to recur. Because Ritchie was no longer having a high rate of tantrums, he was able to participate in many activities that he had not experienced in several months. For instance, his parents began taking him out to dinner and bringing him on shopping trips. In addition, Ritchie enjoyed again going on trips and vacations with his parents and older brother. At school, Ritchie’s classmates no longer seemed to fear him. Moreover, a major goal of Ritchie’s teacher was to place each of her students into an integrated class for the first grade. At first, she was quite convinced that Ritchie would not be a candidate for integration. However, midway through the school year she seriously entertained this possibility, and she had Ritchie visit several integrated first-grade classes for the following year. Around this time, the teacher slowly began to add pictures to Ritchie’s communication book to increase his vocabulary. She successfully added “Bathroom,” “Drink, please,” and May I play with the computer?” Ritchie demonstrated proficiency in using each of these additions, and at the time this chapter was written, his teacher was continuing to add new pictures in the hopes that Ritchie will develop a larger vocabulary.

Table 16.1 Example of Instructions for Functional Communication
Training Provided to Ritchie’s Parents and Teachers
The goal is to teach Ritchie to request a break from work by using the communication book. This will be done by beginning with full physical prompts and then fading the prompts as quickly as possible until Ritchie responds independently.
Initially, training will require 1 : 1 training, and it is important that sessions are run daily and consistently.

INITIAL TRAINING
PHASE I
All sessions should be done while Ritchie is asked to work. First, full physical prompts should be used to assist Ritchie in using the communication book to request a break.

1. Have Ritchie briefly attempt the task.
The duration of time that Ritchie should be required to work before prompting begins should be less than the amount of time that he can typically tolerate before becoming upset. For example, if Ritchie typically tolerates working for 2 minutes, the prompts should begin after 1 minute. If Ritchie begins to tantrum during the 1 minute, it is important to work through the problem behavior and still wait a full minute before prompting him to request a break.

2. After the specified amount of time, say to Ritchie, “Ask for a break.”
3. Guide Ritchie’s hand to the communication book and help him to point to the picture representing a request for a break.
4. After he points, pull his materials away and allow Ritchie to take a break for about 1 minute.
5. Once again, briefly present work materials to Ritchie and then repeat from step 1.
Once Ritchie successfully points to the pictures 3 to 5 times in a row using the above steps, the full physical prompts can begin to be faded. This will be done by following the steps described in Phase II.

PHASE II
1. Have Ritchie briefly attempt the task.
2. After the specified amount of time, say to Ritchie, “Ask for a break.”
3. Guide Ritchie’s hand to the communication book and wait about 5 seconds to see if he will point to the picture independently. If he does not, physically prompt him to do so.
4. When Ritchie points to the picture, pull his materials away and allow Ritchie to take a break for about 1 minute.
5. Once again, briefly present work materials to Ritchie and then repeat from step 1.
Once Ritchie successfully points to the picture 3 to 5 times in arrow, once his hand has been guided to it, the physical prompts can be faded further. This will be done by following the steps described in Phase III.

PHASE III
1. Have Ritchie briefly attempt the task.
2. After the specified amount of time, say to Ritchie, “Ask for a break.”
3. Guide Ritchie’s hand only part way to the communication book and wait about 5 seconds to see if he will continue to bring his hand to the communication book himself and point to the picture. If he does not, physically prompt him to do so.
4. When Ritchie points to the picture, pull his materials away and allow Ritchie to take a break for about 1 minute.
5. Once again, briefly present work materials to Ritchie, and then repeat from step 1.
Once Ritchie successfully points to the picture 3 to 5 times in a row using the above steps, the prompts should be faded further. This will be done by following the steps described in Phase IV.

PHASE IV
1. Have Ritchie briefly attempt the task.
2. After the specified amount of time, say to Ritchie, “Ask for a break.”
3. Now, only touch Ritchie’s elbow and wait about 5 seconds to see if he will bring his hand to the communication book himself and point to it. If he does not, physically prompt him to do so.
4. Following the message, pull his materials away and allow Ritchie to take a break for about 1 minute.
5. Once again, briefly present work materials to Ritchie and then repeat from step 1.
Once Ritchie successfully points to the picture 3 to 5 times in a row using the above steps, the physical prompts should be completely faded. This will be done by following the steps described in Phase V.

PHASE V
1. Have Ritchie briefly attempt the task.
2. After the specified amount of time, say to Ritchie, “Ask for a break.”
3. Wait about 5 seconds to see if he will bring his hand to the communication book and point to it independently. If he does not, gently touch his arm.
4. After Ritchie points to the picture, pull his work materials away and allow Ritchie to take a break for about 1 minute.
5. Once again, briefly present work materials to Ritchie and then repeat from step 1.
Once Ritchie begins to request a break without any physical prompts, the verbal prompt can be faded by following the steps in Phase VI.

PHASE VI
1. Have Ritchie briefly attempt the task.
2. Gradually increase the amount of time before you say to Ritchie, “Ask for a break.”
This should be done until Ritchie requests a break without any prompts.

Despite these encouraging outcomes, Ritchie continues to display significant symptoms and deficits. Though the frequency of his tantrums has decreased substantially as the result of treatment, he continues to have many symptoms of autistic disorder (and associated symptoms of ADHD). Ritchie continues to be somewhat withdrawn, and he still engaging in stereotyped and ritualistic behaviors (e.g., body rocking). Despite the fact that the Ritalin appeared to significantly decrease his hyperactivity and increase his attention span, Ritchie continues to have some difficulty remaining in his seat and attending to his teachers for long periods of time. Although Ritchie may eventually attend integrated classes, he will likely always require a special education teacher to ensure that he is provided with the intense level of teaching that children with autistic disorder typically require to learn new things. In addition, making friends will probably always be difficult for Ritchie.

DISCUSSION

Autistic disorder is relatively rare in comparison to most, if not all, of the other disorders covered in this book. Although prevalence estimates have varied to some degree from study to study (cf. Gillberg, 1984), most researchers agree that autistic disorder occurs at a rate of approximately 2 to 5 per 10,000 people (American Psychiatric Association, 1994). Rates of autistic disorder are roughly 4 to 5 times higher in males than in females, although its prevalence between the sexes appears to vary, depending on the IQ of the child. As noted earlier, approximately 75 % of all persons with autistic disorder have at least a mild level of mental retardation (Waterhouse, Wing, & Fein, 1989). However, autistic disorder is more prevalent in females with IQs under 35, whereas autistic disorder is prevalent in males with higher IQ ranges. Thus, females who develop autistic disorder are more likely to exhibit more severe mental retardation. The reasons for this sex difference are not known (Volkmar, Szatmari, & Sparrow, 1993). No other demographic differences in the prevalence or nature of autistic disorder (e.g., racial, cultural) have been firmly established.
In addition to the features that make up the formal DSM-IV definition of autistic disorder, the disturbance is frequently associated with other problematic symptoms. For instance, persons with autistic disorder may have a range of behavioral problems including hyperactivity (as was true for Ritchie); short attention span; poor impulse control; aggressive, self-injurious behaviors (e.g., head banging); and temper tantrums. Children with autism may display peculiar or unusual reactions to various forms of environmental stimulation (e.g., high pain threshold, extreme aversion to being touched). Disturbances in mood or the expression of emotions are common associated features of autistic disorder (e.g., laughing or crying for no apparent reason). Moreover, persons with autistic disorder may show no emotional reaction to situations or objects that most individuals would react to (e.g., display no fear to situations or a large, aggressive dog), yet respond with excessive emotionality to harmless or trivial objects or situations (e.g., extreme distress upon discovering that a piece of furniture has been moved). In adolescence or early adulthood, persons with autistic disorder who have the intellectual capacity for insight have been observed to develop depression in response to the realization of their serious impairment.
By definition, the onset of autistic disorder is prior to age 3. Once it emerges, autistic disorder follows a continuous course (i.e., unlike some disorders, it is not generally characterized by alternating periods of improvement and recurrence). Nevertheless, the long – term course of autistic disorder is variable across individuals. Some children with autism deteriorate behaviorally when they reach adolescence, whereas other children show improvement. Research has indicated that the presence of language skills (i.e., ability for communicative speech) and higher overall intelligence may strongly predict a more positive long – term prognosis. Nevertheless, the little research that does exist on the long – term course of autistic disorder shows that only a small proportion of these children enter adulthood with the capability of living and working independently. Those who do achieve some degree of independence nonetheless continue to display problems with social interaction and communication, along with constricted interests and activities (American Psychiatric Association, 1994).
Thus far, there are no powerful treatments for autistic disorder. Most of the treatments developed to date have focused on problematic associated features of the disorder, such as disruptive or self-injurious behaviors. Biological treatments such as psychoactive drugs (e.g., Ritalin, frequently used in the treatment of ADHD; fenfluramine, an appetite suppressant) and vitamin therapy (e.g., vitamin B6) have not produced significant or lasting improvements in intellectual level, sociability, or hyperactivity (for a review, see Holm & Varley, 1989). Many of the psychosocial interventions for autism have relied heavily on the learning theory principles of reinforcement and punishment to improve patients’ skill of living and to curtail behavior problems. As was illustrated in Ritchie’s case, these treatments have been used in the effort to improve the communication skills of children with autism (Durand, 1990; Lovass, 1977). In addition, such treatments have been employed to improve socialization skills (i.e., increase the interest and frequency of social interaction with other people). Whereas behavior therapy has increased the frequency of social behaviors, such as playing with toys or other children, these treatments have not shown considerable positive effects in changing the quality of these interactions (e.g., the ability to initiate and maintain friendship with other children; Durand & Carr, 1988). However, an investigation that included an extremely time-intensive behavioral treatment (more than 40 hours per week for more than 2 years) found the psychosocial interventions could produce meaningful and lasting improvements in the intellectual and social abilities of children with autistic disorder (Lovaas, 1987). For instanc, Lovaas (1987) reported that 47 % of children with autism who were treated with the intensive program had achieved normal intellectual and educational functioning by the first grade (compared to none of a group of children with autism who received a less intensive treatment). Despite these promising results, some researchers have noted that these treatments may be seriously limited by their poor practically (i.e., very expensive and time-intensive); others have argued that, given the potential for substantial benefits (i.e., intellectual functioning within the normal range), the “ends” provide resounding support for the future to develop more effective and practical treatments for autistic disorder.

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