Identification & Inclusion: A Method for Reducing Mental Stress among Children with Autism in Regular Schools in Resource Limited Settings

Abbreviations

ADHD: Attention Deficit Hyperactivity Disorder; OCD: Obsessive Compulsive Disorder; ASD: Autism Spectrum Disorder; CDC: Centre for Disease Control and Prevention; CLE: Concentrated Language Encounter; IEP: Individualized Education Plan.

Introduction

A good mental health state is very vital for any individual to live and achieve full potential; having the ability to do meaningful things, and cope physically and emotionally with everyday challenges. This is particularly important for children or learners with autism as moving to new environments can be very stressful and can have a negative effect on mental wellbeing. Non-inclusive schools or teaching- learning environments can be very irritating to learners with autism as they are easily upset with changes in their routines. This may trigger mental health conditions such as anxiety, depression and attention deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD) among others [1].

Autism or autism spectrum disorder (ASD) is a developmental disability significantly affecting verbal and nonverbal communication, social interaction which is generally evident before the age of three years, and adversely affects a child’s educational performance [2]. It represents the most severe and phenotypically distinct end of the spectrum [3], hence, the most reliably and validly diagnosed [4]. In other words, autism is the most severe and frequently diagnosed among other autism spectrum disorders (ASDs) and approximately 30-50% of children with autism remain minimally verbal throughout their lives, with little or no functional speech [5]. Most children diagnosed with autism have severe language impairments or delays, and researchers had estimated that as many as half of all children with autism are non-verbal. Lim [6] opines that a delay in the development of speech and language is one of the most identifiable deficits in children with autism, compared with typically developing children. The core set of defining features of autism are deficits in verbal and nonverbal communication and restricted and repetitive patterns of behavior in children younger than 3 years [7]. According to Tager-Flusberg, et al. 50% of children with autism do not develop spoken language [8]. It is worth noting that the ability to communicate may essentially determine the level to which children with autism can develop relationships with others and get involve in daily activities at school, home and in the community.

Bakare and Munir maintain that lack of verbal communication is a common symptom presented by over 50% of children with autism [9]. That is, children with autism are unable to communicate as their peers do since they may have difficulties to develop language skills and understand what others say to them. As a result, they may not use words to communicate. Hence, many educators may be faced with the demands to teach children with autism in their classes. Therefore, it is important for teachers to know the symptom presentations of children with autism and be able to identify such children in their classrooms in order to give them individual attention. This is done by providing accommodations and making modifications in the teaching- learning process and environment.

Autism can affect a child from any race or background. Globally, the prevalence of autism is on the rise. The Centre for Disease Control and Prevention (CDC) released new data on the prevalence of autism in the United States. This surveillance study identified 1 in 68 children (1 in 42 boys and 1 in 189 girls) as having ASD [10]. In Cameroon, there has been a steady rise in the number of children with autism; overall, it was estimated that 100,000 children were affected by autism in 2011 [11] and at least 130,000 in 2013 [12]. One child out of 50 in Cameroon has autism [13]. However, many children with autism are not being identified early enough [11]. Diagnosing autism appears to be one of the most important steps in supporting children with autism [13]. It is worth mentioning that earlier diagnosis is mandatory in order to allow for earlier intervention [14].

Research indicates that many children with autism can be identified as young as 18 months Baron-Cohen, et al. [15], but a large number of these children are not identified until they are of school age [15]. It is usually prior to the third year of the child’s life that autism is evident [16]. Autism is often diagnosed in pre-school at about the age of four years; however, it can be reliably diagnosed much earlier, often by the age of two years if symptoms are clear and professionals are knowledgeable [17]. More than 75% of children with autism were identified through the school system [18]. Therefore, it is necessary to identify this special group of children early so that appropriate education programs and services may be provided at an early age to support learning and development. This is very necessary as it may go a long way to prevent mental health issues, which may arise due to inability to cope with learning in a non-inclusive environment. Variety of general developmental screening tools are available to practitioners and a variety of measures available for use in diagnosing autism. However, one major criticism of these measures is that most are unable to differentially diagnose among the ASDs [16]. General developmental screening tools are appropriate for use with unselected primary care populations and are likely to detect ASDs in many young children because of associated language and cognitive delays. However, they do not differentiate children with autism from those with other developmental disorders, and data are not available on sensitivity for detection of ASDs. Similar to other developmental screening measures, ASD- specific screening tools may rely entirely on parent report, or they may require direct observation and engagement by the clinician. Parent-report tools often have the advantage of being brief, inexpensive, and practical in the office setting [19]. Explaining further, these authors state that the people who know the child best are surveyed and can describe the child’s behavior over time in a variety of settings rather than being constrained to sampling behavior in one setting at one point in time.

Despite the fact that the prevalence of autism is on the rise due to awareness and that teachers are better placed to identify children with autism in pre-school, some children in Cameroon are not identified. Currently, in Cameroon there is no documented screening technique or procedure that has been fully validated and shown to be effective in identifying children with autism in our nursery and primary schools. As a result, these children are rejected by regular schools and hence, they end up on the streets as “foolish” persons or “morons” [11]. An effective diagnostic method for autism would be invaluable for the early identification and prompt institution of special education support or services.

Given that the number of children with autism in Cameroon is on the rise, early identification is paramount as teachers may be faced with the challenge of teaching these children, while they may be undergoing mental stress. According to Eta [18] in many children with autism anxiety may be triggered by difficulty participating in social activities and significant sensory sensitivities to lights, tastes, smells and loud noises. Hence, teachers need to be trained on how to identify children with autism in order to provide them with appropriate support early enough, promote learning and prevent mental health conditions. It is of the utmost importance to identify and assist children with autism to learn in inclusive environments in order to achieve their maximum potentials and live independent lives like typically developing children. According to Batshaw, et al. [19] inclusion means educating individuals with disabilities alongside those without disabilities. Inclusive classrooms are expected to expose all learners to the same learning environment. Therefore, this study was carried out to establish a comprehensive method for the identification of children with autism in regular classrooms in resource limited nations.

Materials and Methods

The study design and sampling techniques are presented below.

Results

School records: A total of 288 children’s records from the two schools were studied. The number of pupils‟ records consulted and those selected per school is presented in Table 2 below.

Table 2 shows that a total of 288(100%) pupils‟ records were studied and 44(15.3%) pupils were selected because their performance was 50% and below in language activities that is, pre-reading, expression by gestures, oral expression, rhyme and storytelling.

Discussions with Teachers: Teachers were asked to give their individual perspectives regarding communicative behaviors, social interaction and restrictive, repetitive and stereotyped behaviors and interests (symptoms of autism) of the 44 children (earlier identified through the pupils‟ records) as observed on the playground and other activities that involved free play (Table 3).

From Table 3 above, it can be seen that discussions with the teachers confirmed most (34, 77.3%) of the children identified through records as manifesting with symptoms of autism.

Anecdotal Case History: An anecdotal case history checklist completed by parents gave their opinions about their children’s speech and language developmental milestones (Table 4).

Twenty-six (76.5%) out of thirty-four children confirmed earlier by teachers‟ discussions as having symptoms of autism were retained after parents ‟opinions. Eight children were eliminated because they were considered to have Asperger‟s syndrome. DSM-IV-TR Criteria: The modified version of the DSM-IV-TR definition of Autism Spectrum Disorders (ASDs) diagnostic criteria was used to diagnose eighteen (69.2%) pupils out of the 26 children who were selected through informal methods (Table 5).

Teacher Rating: To make sure that the children with Asperger’s syndrome or pervasive developmental disorder- not otherwise specified are not included in the sample. This method (teacher rating) was used to confirm the diagnosis of autism (Table 6).

Table 6: Total Number of Pupils Confirmed as having Autism. *= Excludes pervasive developmental disorder not-otherwise specified From Table 6 above it can be seen that 15 out of 18 children were confirmed as having autism because they had below average scores in their speech/language and communicative behaviors, while the three children with average scores were considered as having Pervasive developmental disorder not- otherwise specified, as such were dropped. Gender: Only two girls were identified in each of the schools given a total of four girls and eleven boys diagnosed as having autism (Table 7).

Discussion

There is little or no information on identifying children with autism in regular classrooms in Cameroon. This is perhaps due to little awareness about autism and lack of resources [11]. In their large-scale prevalence study of ASDs, Yeargin-Allsopp and colleagues found that more than 75% of children with ASDs were identified through the school system [14]. This study which was aimed at eliciting a comprehensive and systematic method of identifying children with autism in a regular classroom serves as a first step in understanding autism and how to reliably diagnose it in a regular classroom in a resource constrained setting like Cameroon. This study was keen in bringing out an eclectic method of diagnosing autism since early diagnosis and treatment is paramount for better outlook as language acquisition before the age of five is crucial for speech and language development [6]. Identifying children with autism in regular classrooms will reduce the distress both parents and teachers of these children face as they can be assisted to study and achieve their maximum potentials and prevent mental disorders among children with autism. In order to identify pupils with autism from the two nursery schools selected for the study, the researcher first of all used informal methods of identification. This is in line with research findings which stipulate that in order to diagnose someone with autism the specialist needs to do some testing which includes physical examinations, interviews, questionnaires, observations, and sometimes blood tests [21, 22]. This is why methods such as schools records, discussions with class teachers and the use of questionnaires were adopted to identify pupils with autism. Results of this study showed that based on school records about one sixth of the total number of children who presented with at least one of the characteristics of ASDs were selected after scrutinizing their first and second end of term reports in the Head Teachers‟ Offices. The aim was to check the performances of each child in language activities. This is in accordance with Min and Wah who hold that over half of the population of children with autism is affected by some sort of language impairments [23]. During this process pupils who had average (50%) and below average (00-49%) scores were retained and those who had above average (50%) were dropped as shown in Table 2. This is because they were considered as not having difficulties in communication which is typical of children with autism.

The study also revealed that discussions between the researcher and the teachers of the children selected through school records confirmed most of them as having characteristics of autism (i.e. speech/language difficulties, impairment in social interaction and restrictive, repetitive and stereotyped behaviors and interests). as shown in Table 3. Discussions with the teachers was carried out based on the premise that teachers are very important adults in the lives of learners, and the fact that teachers are well placed to spot possible autism in school-age children. This is because they are experienced with the range of skills children present at a given age and can watch children interacting together [17]. Also, Min and Wah concur that speech and language assessment for children with autism typically comprises several elements, including behavioral observation of the child’s communication skills in free play [23]. The teachers testified that most of the children presented with deficits in communicative behaviors and social interaction, and restrictive, repetitive and stereotyped behaviors and interests. Furthermore, it was found that parents‟ reports gotten through the administration of the developmental history checklist confirmed that most of the children who were selected through school records and discussions with their teachers manifested with symptoms of autism. This is in line with research findings that the use of multiple assessment methods, which incorporate formal assessment, observation and parent’s report, could generate a more valid language profile for a child with autism as compared to the use of a single assessment technique. This is supported by Min and Wah who maintain that this strategy is an alternative assessment protocol in a setting with limited resources [23].

Again, it was discovered that most of the children were diagnosed as having autism after the administration of the diagnostic test to their teachers (Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition, Revised- Text [DSM-IV-TR]).This test was important because it provided a differential diagnosis of the three most frequent ASDs (.i.e, autism, Asperger’s syndrome and Pervasive Developmental Disorder Not-Otherwise Specified) and the researcher’s intention was to diagnose children with autism. The DSM-IV-TR is the most current version of the official diagnostic guide for diagnosing Mental Health Disorders such as autism spectrum disorders (ASDs) and is being used as a diagnostic reference [24]. However, it has been revealed by literature that no one assessment method or diagnostic criteria can reliably differentiate among the three core ASDs (that is, autism, Asperger’s syndrome and pervasive developmental disorder- not otherwise specified), not even the DSM-IV-TR. It is in line with this view that the researcher decided to design a questionnaire that was completed by the teachers of the children to confirm the diagnosis of autism. In addition, parent-report instruments that characterize pragmatic difficulties on the autism spectrum can be complemented by teachers‟ reports in order to evaluate reliability [25]. Furthermore, this method (teacher rating) is useful because more emphasis is placed on behavioral outcomes than on broad perceptions about a child’s status [26].

It was realized that after administering the questionnaire to determine the pupils’ communicative competence with regards to speech production, expressive/receptive and verbal/nonverbal language skills to their teachers, the children identified as not having autism were dropped as shown in Table 6. This is because they presented with less severe symptoms of autism with respect to their speech/ language and communication behaviors. That is, they had average scores, hence, were considered as having pervasive developmental disorder not-otherwise specified. This supports the fact that the DSM-IV-TR has been criticized for not being able to reliably differentiate between the three core ASDs. The indicators used were considered to be the most frequently used to determine speech/language and communication problems and were appropriate for the pupils‟ level.

The purpose of using this instrument was to separate pupils with severe symptoms presentation in speech and language from those with less severe symptoms. Fifteen children had below average scores in their communicative behaviors and they were confirmed to have autism. This is confirmed by the fact that children with autism do not use full words by age two nor meaningful phrases or sentences by age three [25]. Clearly, schools play an important role in identifying children with developmental disorders such as autism [18]. Interestingly, it was found that out of the total number of children diagnosed with autism most of them were males. This finding conforms with CDC report which states that the prevalence of autism continues to differ tremendously by gender, with boys about 4.5 times more likely to be affected than girls [10]. When children with autism are identified in regular school settings, it is the first step to providing inclusive education through the provision of accommodations and modifications as well as other inclusive practices.

Learners with autism can receive support within the general education curriculum through accommodations and curriculum modifications among other strategies. Accommodations are changes in the way a learner has access to the curriculum or experiences learning. Proper accommodation is made such that it offers equal access to learning without a substantial change in the instructional level or content [27]. Examples of accommodations include allowing more time to complete assignments or texts, making study aids such as calculators and keyboards with sound system available, frequently repeating instructions or the steps involved in performing an activity and helping in taking down notes among others. This allows this special group to learn the same material as typical learners, although in a longer time with a reduced output. On the other hand, modifications to curriculum provide assistance that cause significant changes in the general education curriculum. For example, teaching less challenging spellings and expecting the learner to learn four or two instead of 10 “ing” words required to learn by his/ her classmates. It is worth mentioning that modification is considered carefully because reducing expectations for the learners with autism can lessen their chance of furthering their education or being career ready upon completion of the program [27]. Curriculum modifications may also include supports that allow a child to participate without academic expectations, such as using a calculator for simple mathematical problems or special sound systems for better comprehension during learning [21].

The goal of inclusion can be achieved through a number of inclusion practices such as individualizing the content to meet specific needs. In furtherance, the inclusive class provides accommodations, modifications, supplementary supports, and collaboration with the special education staff for special needs learners [28]. But, most often in less developed countries children with special needs are integrated and not included. That is, these children are put in regular schools whose environments, curriculum, teaching methods and aids are not modified and adapted to meet the needs of this special group [29]. In addition, other inclusion practices such as co-teaching and high-leverage practices in Special Education cannot be underestimated.

In co-teaching, the special educator shares the classroom with a general educator and both teachers take joint responsibility for all the learners in the class regardless of their abilities [19]. Some examples of co-teaching are one teach/one observe, parallel teaching, alternative teaching, and team teaching among others. According to Scruggs et al. [28] the special educator might have some issues with this method but these problems can be solved by using technology for self-learning in order to gain mastery of unfamiliar general education content. In 2011 the Council for Exceptional Children created recommended practices for all special educators in Grades K12 (that is, from preschool to primary and secondary education). The 22 high-leverage practices compose of four aspects of practice, which are collaboration, assessment, social-emotional- behavioral practices and instruction [29]. The end goal for inclusive education is an inclusive society where opportunities are open to all Eta VEA [30], in order to learn based on their individual abilities. Educational programs must be must be relevant to the learner’s needs and address the individual’s strengths and difficulties. Each learner’s developmental level and requirements for support and goals for independence provide a basis for establishing an Individualized Education Plan (IEP). The IEP contains the learner’s educational program that is directed towards the individual’s needs in order to provide maximum benefits [29]. In addition, the Concentrated Language Encounter (CLE) Method could be used as a treatment method in teaching this special group of children. This method involves the reading and interpretation of story books carefully written based on the content of each subject to be taught. The story books are read repeatedly to the pupils using strategies such as re- callings, role play and re-telling with the intention to allow them listen to and pronounce words several times. Also, this method incorporates the use of questions, gestures and articulations as well as the clear descriptions of familiar activities during the re-readings and re-tellings of the stories. These together may enhance the acquisition and production of new target words. According to the findings reported by Eta [30] the CLE Method was found to be a good and effective method for assisting children with autism develop and improve speech and language.

Conclusion

Based on the results of the study, this procedure has systematically and reliably identified children with autism. Therefore, we recommend that this method be employed in identifying children with autism and the other ASDs in regular classrooms in Cameroon and other resource- constrained countries in Africa. This will ensure that children with autism are diagnosed early and given individual attention during the teaching-learning process. For example a carefully designed program for speech-language training through the CLE Method might utilise a child’s unimpaired ability to perceive speech stimuli in order to facilitate speech and language production. This could decrease various mental challenges they face and reduce the frustration their parents and teachers go through. This may in turn reduce the number of children on the streets due to inability to cope with the general system of education in resource limited nations.