8-Jan-09 8:30 AM CST

Autism Spectrum Disorders

Autism is a devastating developmental brain disorder that manifests itself in the first two or three years of life with serious impairments in cognition, communication, and social interaction. Some cases are far more serious than others, and consequently, the concept of a spectrum of impairment has emerged in recent years. On this spectrum, the most severely affected individuals are diagnosed with low functioning autism. Usually those diagnosed with low function are also considered to have coincident mental retardation. Less severely impaired individuals with more normal cognition are generally diagnosed with high functioning autism. The dividing line between high functioning autism and Asperger syndrome is not clear, and the two labels are often used interchangeably, but a child may be more likely to be diagnosed with Asperger syndrome if he appears to be bright. Other rare congenital disorders considered to belong to the autism spectrum include Rett’s disorder and Childhood Disintegrative Disorder. Many children are given the diagnosis of Pervasive Developmental Disorder (PDD) instead of autism, but for all intents and purposes these two diagnoses are interchangeable.

“The New ADHD”?

I’m often asked, “Isn’t autism the new ADHD?” By this the questioner means, “Isn’t this just the latest brain chemical imbalance fad that parents are using to excuse bad behavior in their children?” No, it isn’t, but I can understand why some might conclude that this is the case. Autism and Asperger syndrome are constantly in the news, and we’re informed that their incidence is soaring. Children with this diagnosis are, indeed, very poorly behaved if they haven’t received effective intervention. But autism spectrum disorders aren’t purported to be due to a brain chemical imbalance. Rather, the evidence suggests that serious defects in brain anatomy and function are present prior to birth[1]. These manifest themselves later, as the child fails to meet expected developmental milestones, such as speaking and other cognitive skills, that normally occur before the age of three.

An experienced evaluator can recognize autism as early as age eighteen months, although more commonly children are diagnosed sometime between their second and third birthday. Generally, very obvious difficulties like failure to speak or even communicate by gesture are apparent by then. Although the average person thinks of a child with autism as principally being socially withdrawn, this actually is not the most prominent feature of autism. Rather, failure to communicate, and a level of function far below what would be expected at a given child’s age are more ominous signs that something has gone seriously awry in an autistic child’s development. In fact, children with autism are commonly affectionate toward those they know well, not completely withdrawn, as the conventional wisdom suggests. In fact, totally unconnected aloofness is more likely to be associated with severe mental retardation than with uncomplicated autism.

Asperger syndrome is understood by most experts to represent a milder form of autism. Typically, Asperger children do spontaneously develop speech, although it is usually at least somewhat delayed. Some even may be precocious readers who teach themselves to phonetically decode at an early age, but generally it is later discovered that they read without an age appropriate level of comprehension. Asperger children suffer the same deficits in social understanding and ability to connect with others that children with autism do, but it’s less obvious in the preschool years. They are often identified for the first time when they enter school, because their social and learning difficulties become obvious in the more challenging environment outside the home.

Early Intervention

Because young children’s brains are still developing throughout childhood, significant functional gains can be realized if treatment is undertaken early enough, while the brain is still pliable. Applied Behavioral Analysis (ABA) is an autism treatment first developed by O. Ivar Lovaas, Ph.D., a Skinnerian behaviorist, in the 1970s. It consists of a series of exercises, known as “drills” that break complex skills into smaller pieces that are easier to learn. Once all the steps of a skill are learned in this manner, they are practiced together, resulting in the ability to perform the skill. The child, who is often preverbal, is motivated to participate enthusiastically in the drills by effusive praise and other rewards from his trainer. In time, the special attention is gradually withdrawn as the child’s language skills improve and he learns that success is its own reward. Lovaas found that skills could be taught with enough practice even to intellectually limited children with autism, when presented in this more accessible form.

Since the 1970s our understanding of the immense developmental plasticity of the brain in childhood has increased tremendously, and we now believe it’s likely that ABA stimulates the brain to develop more normally as critical cognitive skills are practiced repeatedly. Researchers have discovered that after successful ABA many children begin to “pick up” new skills by themselves for the first time. They also begin to demonstrate the ability to generalize the skills they’ve learned in ABA to other, similar situations. Neither of these abilities develops spontaneously in untreated children with autism. In fact, some children who complete intensive ABA programs demonstrate large increases in their tested intelligence quotients (IQ), compared to pretreatment values, and some don’t even require special educational services when they start school[2]. Because of these exciting new developments as a result of successful ABA training, many now believe that the autistic child’s brain actually may become more normal as a result of this extended, specially focused practice.

It’s important to understand that ABA early intervention training is most effective when undertaken between the ages of two and four years. For this reason, early diagnosis and prompt referral to treatment is essential. Because parents may be ambivalent or even fearful of receiving an autism spectrum diagnosis, it’s common for evaluation to be delayed. Pastors and counselors can do parents a great service by encouraging them to seek evaluation as soon as they begin to suspect that there may be a problem with their child.

My son, Eric, was diagnosed with autism when he was two years old. He was mute, didn’t understand others’ spoken language, and we were told that he was retarded. ABA was still regarded as experimental in 1990, when we visited Dr. Lovaas’ clinic at the University of California-Los Angeles (UCLA) for the first time, but we were told that this experimental treatment was Eric’s only hope. Today he is an honor student at University of California-San Diego. I attribute his recovery to the God’s grace and the power of prayer, but it’s also clear that one of the means that God used to provide this unusually dramatic improvement was Eric’s early intervention treatment at the UCLA clinic.

Is ABA a Biblical Intervention?

What are we to make of the fact that the only technique of proven effectiveness for the treatment of autism is a behavioral treatment developed by an atheistic Skinnerian? This is an important question to consider, since Christian parents sometimes choose not to enroll their children in ABA treatment because of its behavioral roots. This wasn’t an issue for me, as I hadn’t yet heard of this concern when Eric was diagnosed, but it troubled me when I was told, much later, that I shouldn’t have enrolled my child in an ABA program. I wondered why God would ordain that a technique based upon atheistic principles be the only one clearly proven to be an effective treatment for autism.

I asked my pastor, and he explained to me that ABA is effective, not because the atheistic beliefs undergirding behaviorism are true, but because its technique is consistent with biblical principles. He reminded me that God created man and many animals with the ability to be trained to perform tasks on command by using rewards and punishments. This fact can be observed in nature, and is also demonstrated in God’s special revelation, the Bible. In it we learn that God uses blessings and sanctions to train His people to obey Him[3], and He commands us to train our children this way, as well[4]. Consistent with this Scriptural principle, ABA training is based upon a nonnegotiable expectation of obedience to the trainer, which is established prior to beginning the skill training, and is the foundation for it. The trainer rewards compliance to his commands, as presented in the skills drills, and sanctions disobedience. There literally could be no successful ABA training without it.

So when behaviorists insist that they have discovered a “natural law” which is supportive of atheism and evolution, Christians must insist that they have rather co-opted a Scriptural principle, decreed by God, evident throughout nature and revealed in His Word, and have assigned a competing interpretation to that principle. Christians therefore need not reject this technique because of the assumptions of its creators, but rather must insist that it is a successful technique precisely because it is consistent with Scriptural principles.

Excuse For Poor Behavior?

Can an autism spectrum diagnosis be used as an excuse for poor behavior? It certainly can be. Many parents will tell you that their autism spectrum children can’t possibly meet society’s standard for behavior, and that it’s cruel even to try to make them do so. Christian parents generally agree that God’s Word teaches that they need to train their children consistent with the standards of God’s Word[5]. However, after making heroic efforts over a protracted period of time, they often give up, concluding that autism spectrum children just don’t respond to biblical child training.

But how can this be true? God’s Word tells us that it’s sufficient for any challenge that we may face in life[6]. Special needs people are found throughout the Scriptures, so their presence among God’s people is assumed, but nowhere do we find a statement that exempts them from God’s standards for other human beings[7]. Therefore it can’t be true that autism spectrum children can’t be trained according to Scriptural principles.

I believe that the problem here is a confusion of Biblical principle with application. For example, Shepherding a Child’s Heart is a great Christian parenting book. I absolutely wore out my copy during the years when Eric was a child. In my opinion, Tedd Tripp did a fabulous job of teaching essential biblical principles for winning the hearts of children to Christ. He also derived techniques, based upon those principles, which can be used to apply them to the nurture of typical[8] children. But, while fully accepting the principles Pastor Tripp taught, I found that I needed to modify his techniques to reach my very different child in the most effective way consistent with those principles. The principles are timeless and based upon the infallible Word of God. But the techniques are one man’s ideas about how to apply those principles to the Christian nurture of children. They are not, themselves, God’s infallible principles[9].

Parents often don’t understand this distinction, and this may produce misunderstandings. For example, some parents have told me that Shepherding a Child’s Heart doesn’t “work” with autism spectrum children. The truth is that God’s infallible principles are always effective for training all children, but every technique created by fallible men may not be equally successful in reaching the heart of a child with autism.

The challenge in parenting autism spectrum children is to understand how these children are different, so we can derive new techniques that are appropriate to their differences from the infallible principles in the Word of God. This makes it possible to reach them in a way that they can comprehend[10]. We can never compromise on the principles. We must never suggest that autism spectrum children be held to a separate, lower standard or, God forbid, no standard at all. But we must also offer great compassion to our counselees, many of whom will come to us at their wits’ end, convinced that there is no way to apply God’s standard to their particular child’s situation.

As we do this, we also need to recognize that some low functioning autistic children are very difficult to train, and some will not benefit nearly as much from these techniques as my son did. Unfortunately, not all autistic children are bright. Not all will attain a normal, or even nearly normal, level of function, no matter how diligent and faithful the parents are. Pastors and counselors do need to faithfully hold out the hope of improvement as they show discouraged parents what they may be missing in their approach to the discipline and training of their autistic children. But, an approach that insists, for example, “All the children at XYZ Church are to sit quietly in the Sunday morning service by the time they’re four years old,” will doom some families to self-condemnation and failure. Great wisdom is needed to encourage parents to do all they can to develop whatever potential God has placed within their child, while at the same time offering comfort and acceptance to those who appear to be doing all they can, but are not getting the same results from their efforts.

About Psychotropic Medicines

Great wisdom is needed, too, in the question of medicines for this group of children. When high quality early intervention based upon the principles of ABA is received before age four, many children will go on to achieve something like typical function. I’m always saddened when I meet a preschooler who is already taking powerful psychotropic drugs to control his behavior, because the preschool years are the time when ABA should be the treatment of choice. And yet, despite all the best efforts of parents, behaviorists and special education teachers, some autistic children and adults, particularly those with low function, may need medicines to control their behavior sufficiently to enable them to continue to reside safely in their community. Some injure themselves constantly if they’re not medicated. Others may dart unpredictably out into the traffic, or become violent.

I recommend that parents look into other interventions that have been found helpful before they take the plunge into medicating their child. Many parents have found that special diets, such as those which restrict milk protein and wheat gluten, seem to help some autism spectrum children pay better attention and be more successful in controlling their impulses. Some children also respond well to various vitamin supplements. Spectrum children with sensitivity to noise and touch often benefit from desensitization training. All of these interventions are fairly benign, but others you may hear about from parents are not, and some may actually be harmful. It’s always wise to recommend that parents ask their autism treatment professional whether a particular treatment is ineffective or even dangerous prior to committing to it.

Just the Latest Fad?

One reason why people wonder if autism spectrum disorders are just the “new ADHD” is the incredible rise in their diagnostic rate in recent years. Although the evidence is irrefutable that autism is a “real disease”, there certainly may be some over-diagnosis happening today, particularly among those diagnosed with Asperger syndrome, which is the milder variant of autism.

Back in the 1980s, when I was in my psychiatry residency, I saw only one autistic child, who was very low functioning, during three years of training. This was a common experience for the time. Hans Asperger’s groundbreaking paper on mild autism had not yet been translated from its original German, and its existence was as yet unknown in those years. Nowadays most doctors are aware that there is a broader spectrum of abilities, but this doesn’t mean that they’ve received the necessary training to be able to recognize some of the subtler distinctions between autism, Asperger syndrome, and other challenges.

Parents are also better informed than they used to be. They often bring their children to the doctor with the question, “Could my child have Asperger syndrome?” In my experience, I’ve found a few to be quite determined to receive a diagnosis that explains why they are having so much trouble handling their child. And so the combination of doctors who may not have the training to recognize autism spectrum disorders unless they’re obvious, and parents who are sometimes seeking this diagnosis, could lead to inappropriate diagnoses. For this reason, I always recommend that concerned parents get a referral from their pediatrician or family doctor to a university center that specializes in the diagnosis of developmental disorders, to ensure that the diagnosis that they receive is accurate and appropriate.

But over-diagnosis probably isn’t the only reason for the mushrooming incidence of autism spectrum disorders. I’d guess that more precision in diagnosis is also a factor. Not too long ago, children were more commonly diagnosed with mental retardation than with autism. I’m also convinced that many kids with Asperger syndrome once were diagnosed with learning disability. Remember learning disability? There was a time when every kid seemed to be diagnosed with it. When was the last time you met a young child with learning disability? Instead, it seems now that everyone has Asperger syndrome. And this isn’t an altogether bad thing.

Remember that my son, Eric, was initially diagnosed with retardation, because he couldn’t speak. In the bad old days, he would have remained as he was into adulthood, even though he was actually highly intelligent. With the advent of effective interventions, more children with autism will achieve more normal function. What a blessing! Similarly, Asperger syndrome, although it includes cognitive deficits, is not principally a learning problem; so approaching it exclusively as such is inadequate. Increased ability to recognize it for what it is has already resulted in the development of more effective treatments for these children, who typically aren’t diagnosed until they’re too old for early intervention treatments like ABA. We can expect more progress like this in the future.

Do Vaccines Cause Autism?

As I write this, the autism community is buzzing with the news that the parents of an autistic child recently received an award from the National Vaccine Compensation Board because the vaccines their daughter received “caused” her autism. Many parents still believe that mercury in the Measles/Mumps/Rubella (MMR) vaccine causes autism, in spite of the fact that mercury was taken out of all vaccines in 2001, and the incidence of autism is still rising today.

The recent case determination was based upon the discovery that the child had a rare genetic defect in the mitochondria in her cells that was aggravated by the high fever she suffered after receiving 5 vaccines in the same day. So, in other words, the compensation board determined that the vaccines did “cause” her autism, but they did so by the mechanism of high fever, not as a result of mercury in the vaccine “poisoning” her brain cells.

It’s been known for a long time that high fevers cause brain damage in young children. This is why we stay up all night with our feverish children to cool them down. This child suffered brain damage due to an inborn defect of her mitochondria that was activated by her fever. The result was the development of autistic behaviors that presumably might never have developed if her brain hadn’t been injured by the fever.

The take-home message for parents who are concerned that vaccines could produce autism in their children is that it makes sense to consider requesting that their children get their shots one at a time, rather than in bunches, as the child in question did, since receiving several shots at the same time increases the likelihood of a high fever reaction. I’m also concerned that high fevers may induce brain damage in children who may have other genetic vulnerabilities. Asperger syndrome is present in my family history, but I’ve often wondered whether Eric developed severe autism, instead of the milder Asperger syndrome, because he had a high fever the day he received several vaccines at the same time.

How Can Pastors and Counselors Help?

How can pastors and biblical counselors respond in a biblically balanced and prudent way to the autism spectrum “epidemic”? First and foremost, we should seek to be sources of comfort and encouragement to families who are understandably devastated by this diagnosis. We need to be prepared to help bewildered parents whose faith is severely shaken grapple with the question of why God permitted autism to touch their family. We can offer biblical encouragement, based upon the scriptural evidence that autism spectrum children aren’t outside of God’s grace[11] or exceptions to His principles for their nurture[12]. We can also offer practical encouragement that great advances are being made in autism treatment, and many are being helped by early intervention treatments. We should urge parents to seek timely diagnosis and treatment, to take expert advice, and to do prudent things to decrease their child’s risk from vaccines.

But ultimately, their comfort and safety must be found in their faith that a sovereign God designed their child and planned all the days of his life before any had yet occurred[13]. My life as an autism spectrum parent, and that of my son, are trophies of God’s grace to those who look to Him in faith and wait upon Him in prayer. May God grant all of the parents we seek to help the grace to do the same.

Biographical Note:

Laura Hendrickson, M.D. is a former board certified psychiatrist and NANC certified biblical counselor who currently ministers at the Institute for Biblical Counseling and Discipleship in San Diego County. She is the mother of an adult son who has recovered from autism, and is the coauthor of two books on biblical counseling issues. Her new book, Finding Your Child’s Way on the Autism Spectrum: Discovering Unique Strengths, Mastering Challenging Behaviors is scheduled for release by Moody Publishers in February, 2009.

[1] This evidence includes indisputably physical features that occur in conjunction with autism spectrum disorders such as increased head circumference, presence of stereotypies and other abnormal movements, and the frequent coincidence of recognized markers for structural brain malfunction such as seizures, mental retardation, and motor abnormalities like poor muscle tone and cerebral palsy. I recommend The Neurology of Autism, by Mary Coleman, M.D. (ed.), (New York: Oxford University Press, 2005) to those with medical training who wish to learn more about this subject.

[2] McEachin, J.J., Smith, T., & Lovaas, O.I. (1993), Long-term Outcome for Children With Autism Who Received Early Intensive Behavioral Treatment, American Journal on Mental Retardation, 97, 359-372.

[3] My pastor taught me that God used positive and negative sanctions (“rewards” and penalties, blessings and curses) to train His people to obedience as recorded in the Old Testament historical books, and presented this as a principle throughout the poetical and prophetical books. In the New Testament the deaths of Ananias and Sapphira and the sanctions applied to those misusing the Lord’s Table make it clear that this principle continues in force for New Testament believers.

[4] Proverbs 22:15; Ephesians 6:1-3.

[5] Deuteronomy 6:6-9; Ephesians 6:4

[6] 2 Timothy 3:14-17; Psalm 19:7-11; 2 Peter 1:3-4

[7] See for example Leviticus 19:14; Deuteronomy 27:18, where God’s people are commanded not to mistreat a blind man. This special need is acknowledged, but no special modifications are offered to suggest that his training or worship requirements should be different because of his differences.

[8] Autism spectrum parents prefer the word “typical” to “normal” in describing non-autistic children, because the word “normal” suggests that their children are abnormal, which is an emotionally loaded term.

[9] It should go without saying that where God does command certain techniques of child training, such as the use of corporal punishment, these techniques are infallible and must be used.

[10] My new book, which is due to be released in January of 2009, Finding Your Child’s Way On the Autism Spectrum: Discovering Unique Strengths, Mastering Behavior Challenges (Chicago: Moody Publishers), is a attempt to share the techniques I discovered with other autism spectrum parents.

[11] Autism spectrum children, like all human beings, are made in the image of God (Genesis 1:27), and are sinners who need a Savior (Romans 3: 23,24).

[12] See footnote 7.

[13] Psalm 139: 13-16