.Lets Imagine you walk up to three people in a park. They all have their right sock and shoe off and they are all rubbing their right foot. They are all wearing fitness and jogging wear. They all look focused and intent on what they are doing, paying little attention to what is going on around them. Without further information and just looking at behavior patterns you may come to conclusion that they are all in pain and that they may all have injured their foot. But, this may or may not be accurate.
The way we currently diagnose autism spectrum disorders is similar. We reference observable behavior patterns, following criteria laid out for us on the DSM V and use measurable standardized instruments to gather information on these behavior patterns.
As more and more people diagnosed with autism move into adulthood they are expressing many and varried thoughts and ideas regarding their experience having an ASD diagnosis, what it means to them, how or whether they felt valued, and whether they felt that the interventions that they were given were effective. What can be observed is that all of their experiences are different and that they truly experience their "autism" uniquely.
It is also clear that at any one point in time, comparing two "similar" children diagnosed with ASD cannot in any way predict long-term outcome. Some children apparently "recover" by adulthood. Others remain "impaired" in many ways, but have found ways to express themselves through writing. Other individuals require life-long support.
So, what does this say about diagnosis. One example to consider is in regards to Jenny McCarthy's son. Whether you are accepting of biomedical interventions or not, the reception of her son's "recovery" from autism in the broader community has been varied. Some, who have never actually met him, say that his symptoms more readily fit Landau-Kleffner Syndrome. Jenny, however, disagrees.
The symptoms for Landau-Kleffner? Loss of verbal expression as a toddler, language comprehension struggles, and seizures. While this disorder is diagnosed with an EEG, observational criteria would have a child with this diagnosis potentially fit in the ASD diagnostic criteria. Outcomes for this population of kids is quite positive for strong language "recovery". Who is to say then that kids with Landau-Kleffner are NOT in fact autistic? If they fit the diagnostic criteria then in our current diagnostic process one does not rule out the other.
Back to the observation of the people on the bench at the park. One person may have twisted her ankle after having stepped off the running path. She is feeling quite a bit of pain. Another had been sitting for awhile, checking e-mails when his foot fell asleep. He is feeling prickles as he works to get blood flowing to his toes again. The third had an injury a few months ago and her doctor wants her to massage her muscles before each run.
If we looked at each person based on behavior me might assume they have the same "disorder". This is, however, far from the truth.
Diagnosis based on observational behaviors is an aging construct. With MRI and genetic technology, as well as biological tests, such as the up and coming Clarifi saliva test we may find that there is quite a bit of variation in the ASD population when it comes to causality, cognitive profile, appropriate therapies, outcome, and self-perception of ASD individuals.
Why is differential diagnosis important? Ultimately people's needs (in all populations) should be addressed on an individual basis based and on their individual profiles. It is my hope that the ASD diagnosis as we currently see it will disappear and in its place we will see the development of support systems and "treatment plans" based a more broad level of cognitive, psychological, and biological investigation that can truly support an individual and their family. And, in the long run help each person with autism be seen as an individual. This is really the only way to move toward a combined neurodiversity and interventionist model of support. Ultimately helping each person, as an individual be accepted as an individual while working to continue to grow and develop as that individual.
Focus on the individual, not a diagnosis will lead to a better world for us all.
It happens countless times a year. A parent sits with me and says "He/She reads really well, but reading comprehension is such a challenge".
Reading comprehension difficulty, to some degree, is such a common occurrence among individuals diagnosed with Autism Spectrum Disorder that it is almost expected as part of the child's academic profile.
What is not consistent, however, is the cause, or causes of the difficulty with reading comprehension. Normally the challenge is not due to one simple cause, but a series of cognitive and processing factors that interplay in making reading comprehension difficult. Very few parents find that simply bringing in a tutor, or having a child practice with a few workbooks addresses the issue in any meaningful way. Rather, directly addressing the core cognitive challenges at the root of reading comprehension difficulties is a much more effective route. It is important, then, to understand what factors are impacting reading comprehension for a specific child and developing an individualized approach to address the issue.
Below are specific cognitive factors that work in conjunction to impact reading comprehension.
Short-Term and Working Memory
Short-term Memory has been described as the "white board of the mind". This is partially true in that it is a format for us to actively focus on our thoughts and incoming information. It has been theorized through Braddley and Hitch's model that Short-Term and Working Memory is comprised three separate functions, the Phonological Loop, The Visuospatial Sketchpad, and the Episodic Buffer. In simple terms, the Phonological loop is responsible for actively holding auditory information as it is being processed, while the Visuospatial Sketchpad is responsible for holding Visual information. The Episodic Buffer helps to organize and sequence information for the purpose of long-term storage. It assists in processing events in sequence.
Efficient reading comprehension relies heavily on the Visuospatial sketchpad that is activated through visualization. If this is weak, then the Phonological loop takes over and information is processed in the language centers of the brain. This is not as efficient and results in a shallower comprehension of the text. Ideally what is read will activate the Episodic Buffer an will be stored in the same way we store experiences in our own life.
A strong Short-Term/Working Memory is necessary for efficient logical reasoning as well as long-term storage. Every individual has a Short-Term Memory (The ability to actively focus on information) and Working Memory (The ability to process information) that function differently from anyone else's. An efficient Short-Term/Working memory allows for the ability to actively focus on multiple things, hold information in mind when distracted by other tasks, and the ability to think flexibly about a topic. It impacts many other cognitive functions.
While many programs and exercises address difficulties with the Phonological Loop, which can be very helpful with other skills, and a few address difficulties with the Visuospatial Sketchpad, very few go as far as working to support the Episodic Buffer. This is primarily due to the interconnected nature of this function and how it is impacted by other cognitive abilities.
Visual processing, particularly the skill of visualization, is an important factor in reading comprehension and leans heavily on the Visuospatial Sketchpad function of Short Term/Working Memory. The ability to draw up mentally an accurate image based on described and imagined information from text helps the reader to comprehend information more effectively. The adage "A picture is worth a thousand words" is incredibly accurate when it comes to reading comprehension. This image must then be filtered through the language centers of the brain when describing what is comprehended to others. One way to see if someone can visualize is to ask them to describe their bedroom. See how they approach the task, ask questions like "what color is your bed spread?" or "where do you keep your clothes?" and evaluate the accuracy and detail of their response.
Only a few really solid programs use research-based methods to address visualization skills on a language/literature level. Lindamood Bell by far the best in addressing these challenges. This may be the key to all reading comprehension difficulties for a child, or may need to be used in conjunction with techniques used to address Short-Term Memory and Comprehension/Knowledge.
With strong visual processing skills that comes with an intact Visuospatial Sketchpad comes an increased ability to sequence events and recall events in sequence in a story. This builds cause and effect reasoning. It helps with concrete comprehension of story.
Inductive reasoning is the ability to pick up on clues in the story to find patterns and to draw conclusions. This requires a strong, efficient, and flexible Working Memory that allows a reader to juggle multiple pieces of information at once in order to identify relevant clues, identify patterns, and come to conclusions.
Theory of Mind
Closely associated with the logical reasoning function of Inductive Reasoning is the Social Cognition process of Theory of Mind. Theory of mind is the ability to take an underlying understanding that another person might have differing thoughts from yourself and then use clues from behavior and situations to reason what another may be thinking or feeling. While it is not often considered, Theory of Mind is an important skill in being able to evaluate the emotions, thoughts, and motivations of characters in a story. The primary way to initially address this is to put the reader into the scenario in the story. This may help them to understand motivations and emotions.
Comprehension and Knowledge Base
In order to comprehend what is read, a readily available store of knowledge must be drawn from to apply to the new text being read. This goes beyond vocabulary and into concepts such as comprehension of time (past, present, future etc), and knowledge of the universe and our place in it (understanding of planets, our country, city etc.). If a person has a base of knowledge and understanding of the world at a second grade level, they will approach text on a second grade level. Even if visualization and reasoning are intact, comprehension is impacted by a limited knowledge base.
Building a comprehension/knowledge base is cumulative. Knowledge is built upon previous knowledge in that an efficient mind connects new information to knowledge learned in the past. The best way to address this issue is to feed someone knowledge any way possible. Visual and experiential teaching go a long way to build understanding not just memorized facts.
By using the Episodic Buffer, information, after it has been processed using Visualization, logical reasoning, and Theory of Mind, can be stored long-term. In a story form, this can be stored as Episodic or Meaningful Memory. This allows the information to be accessed later. To evaluate if this skill is intact, see if your child/student can talk sequentially and in detail about their most recent vacation. If this is a struggle, they will also struggle to recall, globally, details of what they read.
Given short-term memory and visualization difficulties are addressed, this can be worked on by giving a person a platform (a photograph for instance) to discuss their own life experiences, practicing telling experiences in sequence and going over events with an unfamiliar person. Questioning really helps.
Given all functions are intact, many individuals on the spectrum do not read actively. While they read words aloud or mentally, they are not interacting with the text. They make no effort to apply meaning to what they read. This is simply not something that they think to do. An instructor may need to set up a means to facilitate active reading. Some of this is done on an advanced level through frequent questioning throughout the text. Another involves matching pictures to events to specific sentences after they read, building to sequencing pictures for a paragraph or story. Anything that requires them to think about the text rather than expecting that they are doing this automatically.
While everyone approaches what they read with different cognitive strengths and weaknesses, it is important to evaluate a person's reading comprehension ability within a cognitive system. This system, which is comprised of different functions and abilities, can impact reading comprehension at various points in the process. While there are a few best-practice interventions, a one size fits all approach is not the answer. An accurate understanding of cognitive functioning followed by targeted intervention will support the best outcome.
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Lisa works with families who are looking for educational solutions for their children. She has provided services to families in the DFW area for over 10 years.