In 2013, the American Psychiatric Association released the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM-5 is now the standard reference that healthcare providers use to diagnose mental and behavioural conditions, including autism. Autism is known as a “spectrum” disorder because, people with Autism exhibit wide variety of symptoms involving multiple levels of type and severity. Known as neurodevelopmental disorder, Autism Spectrum Disorder (ASD) is specifically characterized by 3 core areas:1

  • Deficit in Social-emotional reciprocity.
  • Deficit in non-verbal communication e.g. eye contact, body language, understanding gestures.
  • Deficits in developing, maintaining, and understand relationships.

As per World Health Organization It is estimated that worldwide 1 in 160 children has an ASD.2Autism diagnoses per 10,000 children in a few countries as follows:

PC :www.focusforhealth.org 

 

PC :www.focusforhealth.org

 

There are around 700,000 people on the autism spectrum in the UK – that's more than 1 in 100.3Although Autism can be diagnosed at any age, the symptoms become apparent at an early age of 2 or 3. Some developmental delays might appear even around 18 months.4Even though there have been many efforts to diagnose Autism Disorder Order(ASD), there remains a need for effective therapy for the core symptoms (as listed above). Research says implementation of early intervention will lead to productive outcomes in autistic adults.5, 6It may improve the cognitive and adaptive behaviour and reduce severity of ASD diagnosis.7Children who received an intervention targeting early social communication skills have shown greater long-term language improvements. These interventions can increase a child’s social communication skills and may result in improved language use, including better long-term language and communication outcomes.8Early intervention can therefore optimize outcomes, improve independence, and lessen long-term costs.9

According to a literature reviewconducted in 2013, the cost of supporting an individual with an ASD and intellectual disability during his or her lifespan was $2.4 million in the United States and £1.5 million (US $2.2 million) in the United Kingdom.10The cost of supporting an individual with an ASD without intellectual disability was $1.4 million in the United States and £0.92 million (US $1.4 million) in the United Kingdom. The largest cost components for children were special education services and parental productivity loss. During adulthood, residential care or supportive living accommodation and individual productivity loss contributed the highest costs. Medical costs were much higher for adults than for children. The substantial direct and indirect economic effect of ASD clearly indicate the need to search for effective interventions involving ever emerging technology.11

It is crucial to develop intervention strategies helping individuals with autism, their caregivers and educators in daily life. Students with ASD require significant therapeutic support during their years in school. A survey of special education data noted that services included speech language therapy for 66.8% to 85.2% of autistic students, while 34.6% to 44.6% of students had behavioural services in place. This study noted that the significant number of students receiving speech language and occupational therapy was “consistent with the severity of communication impairments and with the pervasive effects of ASDs on activities of daily living”.12

The first category of core deficits found in children with ASD is social-emotional reciprocity. They are known to exhibit abnormalities in reciprocal social interaction and difficulties in emotional expression and recognition.13These difficulties span over the developmental stage of a person regardless of cognitive abilities. Recent studies have indicated High Functioning Autism children can engage themselves in higher level of social interactions and more complex emotions compared with low functioning children with Autism. This is probably due to the fact that High Functioning Autistic children, at least partially compensated for their social impairment by utilizing their relatively high cognitive abilities.14-16Social-emotional understanding stand out as major problems as compared to social insensitivity or social disinterest, for high functioning children with Autism.17In particular, high-functioning children with autism shows difficulties in social cognition and in reciprocal peer interaction. Many of the children with ASD are home-educated and unfortunately do not get enough exposure to peer interactions. With regards to poor reciprocity, which is a defining feature in diagnosis of Autism, there are only few assessment tools which help in measurement of impairments in reciprocity Newer assessment tools such as Interactive Drawing Test(IDT) have been researched to facilitate such measurement. A study showed children High Functioning Autism Spectrum Disorder (HFASD), exhibit less collaborative behavior and intend to draw their objects by own.18 Social interactions flow from the notion of sharing. One of the crucial foundations of human evolution is sharing which involves giving up ownership of an object or access to commodity for someone else’s use/benefit.19Absence or less sharing nature may significantly impact on a child’s ability to build relationships which in turn devoid him/her of any social interactions. This can be related to social-cognitive development.20

There is a need for efficacious therapies to address the need of children with ASD exhibiting impairments in social-emotional reciprocity, which in turn can increase their social interactions. Few of suggested methods, as per research can be:

  • Cognitive behavioural therapy (CBT)21
  • Robot Assisted-Therapy(RAT)22
  • Music Interaction Therapy 23
  • One of the newer technologies which have come forward in this respect is Virtual Reality.24

The second category of core deficits found in children with ASD is deficit in non-verbal communication. According to a study, autistic children were deficit in three categories relating to non-verbal communication.In the social interaction category, autistic children engaged in briefer turn-taking sequences than did the other children,and responded less frequently to invitations than did the mentally retarded children. In the requesting category, the autistic children made eye contact with the experimenter less frequently than the normal children. In the indicating category, the autistic children pointed less often to objects out of reach than did the other groups of children.25

  • Social interaction category: Social interaction deficits for young children with autism may reflect deficits in essential social skills. Children with autism spent less time interacting than did children developing typically, had lower-quality interactions when they did play with peers, and spent more time engaged in purposeless or no activity and/or at greater physical distances from peers26 comparisons to typically developing children in identical situations (i.e., during free play activities soon after placement in a preschool program) indicated that children with autism spent less time in proximity to other children, received fewer social initiations from peers, were less likely to focus on other children, produced fewer verbalizations to others, focused less on adults as interactive partners, and engaged in more atypical behaviour. Children with autism spent a larger proportion of time engaged in non-social play (i.e., play that is solitary or near, but uncoordinated with, peers, as well as watching others play), and a smaller proportion of time in direct social play with others. First, it is not the case that children with autism, as a group, engage in no interactions with other children. Rather, available research consistently demonstrates that while children with autism make and receive fewer social initiations, respond to fewer of the initiations, and engage in shorter bursts of interaction, many of these children do participate in social interaction with peers.27Second, these data suggest that social interactions for many young children with autism are not preferred activities; rather, it appears that isolate play, proximal onlooking, or other more challenging behaviours may be the more likely behaviours in “free play” activities where children developing typically are likely, and expected, to engage in social interaction. Compared with children of similar ages, children with autism engage in higher rates of repetitive non-functional movement (generally labelled stereotypic or self-stimulatory behaviour), higher rates of self-injurious or otherwise challenging behaviour, and lower rates of proximity to peers (sometimes described as socially avoidant behaviour).28Taken together, it appears that a complete understanding of the social development of young children with autism and the development of effective interventions for these children will require a detailed analysis of the developmental and functional relations between social interaction and multiple classes of competing behaviours. Further research may elucidate the extent to which early social interaction competence serves as a protective factor, preventing the development of these competing behaviours; conversely, future research may describe ways to replace competing behaviours with competent social skills.29
  • Requesting category: The autistic children's performance, by contrast, suggests a joint attention deficit in addition to a language deficit. An autistic child's language problems may thus be compounded by a developmental impairment of the mechanisms that are the basis for effective communication. If such a deficit is present in autistic children's development, it implies that autistic children's disorder of communication extends beyond a disorder of the symbolic function. A grasp of language pragmatics requires the ability to appreciate the meaning of non-symbolic objects and events in the human environment and their roles in social interactions. When this ability is impaired, the functional aspect of language may be the most disrupted. Impairment of joint attention skills may to some extent affect how well syntax and semantics of the language are acquired; it will certainly affect the acquisition of strategies and techniques for using language effectively in a social context (pragmatics).30Deficits in eye contact, turn-taking, gestures, or verbalizations that indicate requesting objects or action/ attention, responding to others, or protesting (e.g., refusing to participate in an interaction) are perceived by peers, family members, and other individuals as significant limitations in the social-communicative behaviour.31
  • Indicating category: A deficit in the development of joint attention is one of the earliest symptoms of autism, evident before 1 year of age and often before any diagnosis has been made. Compared with children with mental retardation or specific language delay, matched for developmental level, only children with autism show deficits in joint attention. A deficit in joint attention discriminates 80% to 90% of children with autism from those with other developmental disabilities. Infant screening and diagnostic instruments for autism include assessment of deficits in joint attention as a marker for autism.32

The third category of core deficits found in children with ASD is deficits in developing, maintaining, and understand relationships. Children with autism frequently have difficulties establishing friendships. A failure to develop peer relationships appropriate to developmental level is a diagnostic criterion for these children. The theory of mind view of the core deficit in autism – emphasizing the child’s difficulty in understanding that other people have different thoughts, desires, and feelings – predicts crucial difficulties in the reciprocity and empathic pro-social behaviours (e.g. comforting, caring, complimenting, listening) necessary for friendship development. Although the question of whether intimate friendship is possible in autism remains debatable, children with autism and their mothers reported that they do have friends. Children with autism had less stable friendships, met their friends less often, and were involved in different activities with their friend. Activities preferred by children with autism and their friends were more structured (i.e. board games), providing clear, explicitly stated rules and/or activities that do not require high levels of social exchange.33According to one study, children prefer interaction with dogs over interaction with people. The reason for this is the communicative behaviour of dogs is clearly simpler and is not complicated by verbally transmitted communication. They communicate their intentions on a level that people with ASD find easy to understand while human communication uses two signal paths, the nonverbal visual and the verbal-auditive channel.34In another study, parents of autistic children assessed the difficulties with social interaction and understanding. The parents reported lower levels of social skill and social competence than did their children with ASD, though the children’s responses on the questionnaires demonstrate that they do have some awareness of the nature as well as the outcome of their difficulties. The study concluded that children with ASD may have more success in developing friendships in middle childhood but lack the necessary socio-emotional skills to sustain friendships in adolescence.35 

Virtual Reality (VR) for autistic children

It is crucial to develop tools for neurocognitive habilitation enabling children with ASDs to increase their ability to perform daily-life activities.In Virtual Reality, the computer generates a three-dimensional world, places the user within it, and allows independently determined motion by the user with appropriate environmental responses. It produces computer-generated real life experiences. It is better suited for learning than real environment since it (1) removes competing and confusing stimuli from the social and environmental context, (2) manipulates time using short breaks to clarify to participants the variables involved in the interaction processes and (3) allows subjects to learn while they play. The realism of the simulated environment allows the child to learn important skills, increasing the probability to transfer them into their everyday lives.36

iBloomVR's mission is not just to create innovate tools for individuals but to ensure it positively aids the individuals with ASD. We are working with academic researchers, doctors, therapist, and educators to validate that such tools are effective and will have a constructive impact on the lives of individuals with ASD and their families.

Currently, we are running a clinical trial to study The Effect of Virtual Reality on Socialization, Communication, and Specific Autistic Behaviourin Children with Autism. Using a pilot of iBloomVR’s innovative platform, this study will help in understanding how virtual reality as an intervention technique shows improvements on measures of socialization, communication, and specific autistic behaviours in children. In addition to this, our study would also benefit the clinicians in determining future VR modules that would help children with autism prepare for encounters or situations which could be stressful for them in the real world and also train them to effectively perform day to day activities.

References

  1. Centers for disease control & prevention, Autism Spectrum Disorder (ASD), Diagnostic Criteria.
  2. World Health Organization
  3. National Autistic Society, UK. Autism Facts and History
  4. Autism Speaks – What is Autism
  5. Blair Germain, et al,2015, Recent Advances in Understanding and Managing Autism Spectrum Disorders
  6. Srinivas Medavarapu et. Al, 2019, Where is the Evidence? A Narrative Literature Review of the Treatment Modalities for Autism Spectrum Disorders, Cureus. 2019 Jan; 11(1): e3901.
  7. Dawson G., et. al, 2010, Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model, Paediatrics. 2010 Jan;125(1):e17-23.
  8. Elizabeth A. Fuller,Ann P. Kaiser, The Effects of Early Intervention on Social Communication Outcomes for Children with Autism Spectrum Disorder: A Meta-analysis, Journal of Autism and Developmental Disorders https://doi.org/10.1007/s10803-019-03927-z
  9. Franz L, Dawson G. Implementing early intervention for autism spectrum disorder: a global perspective. Pediatr Med 2019;2:44.
  10. Buescher, et al, Costs of autism spectrum disorders in the United Kingdom and the United States.
  11. Buescher, et al, Costs of autism spectrum disorders in the United Kingdom and the United States.
  12. Wei, X., Wagner, M., Christiano, E. R. A., Shattuck, P., & Yu, J. W. (2014). Special Education Services Received by Students with Autism Spectrum Disorders from Preschool through HighSchool. J Spec Educ , 48 (3), 167–179
  13. DSM 5
  14. Hermelin& O’Connor, 1985 Logico-affective States and Nonverbal Language
  15. Kasari, C., Chamberlain, B., &Bauminger, N. (2001). Social emotions and social relationships: Can children with autism compensate?
  16. Sigman, M., & Ruskin, E. (1999). Continuity and change in the social competence of children with autism, Down syndrome, and developmental delays. Monographs of the Society for Research in Child Development, 64(1), v-114.
  17. Bacon, A. L., Fein, D., Morris, R., Waterhouse, L., & Allen, D. (1998). The Responses of Autistic Children to the Distress of Others. Journal of Autism and Developmental Disorders, 28, 129-142.
  18. Tineke Backer van Ommeren, Sander Begeer,Anke M. Scheeren,Hans M. Koot(2011) Measuring Reciprocity in High Functioning Children and Adolescents with Autism Spectrum Disorders
  19. Dunbar,R.I.M  (1993) Coevolution of neocortical size, group size and language in humans
  20. Calum Hartley , Sophie Fisher (2018), Do Children with Autism Spectrum Disorder Share Fairly and Reciprocally?
  21. Karen M. SzeJeffrey J. Wood (2007) Cognitive Behavioral Treatment of Comorbid Anxiety Disorders and Social Difficulties in Children with High-Functioning Autism: A Case Report.
  22. Robins ,K. Dautenhahn,R. TeBoekhorst,A. Billard(2005), Robotic assistants in therapy and education of children with autism: can a small humanoid robot help encourage social interaction skills?
  23. Dawn Wimpory, Paul Chadwick,Susan Nash(1995), Brief report: Musical interaction therapy for children with autism: An evaluative case study with two-year follow-up
  24. NyazDidehbani ,Tandra Allen, Michelle Kandalaft , Daniel Krawczyk ,Sandra Chapman (2016), Virtual Reality Social Cognition Training for children with high functioning autism.
  25. Mundy et. al, 1986, Defining the social deficits of Autism: The contribution of Non-Verbal communication measures
  26. Scott R. McConnell, 2002Interventions to Facilitate Social Interaction for Young Children with Autism: Review of Available Research and Recommendations for Educational Intervention and Future Research
  27. Kennedy & Shukla, 1995 Social Interaction Research for People with Autism as a Set of Past, Current, and Emerging Propositions
  28. Lord,1993 Early Social Development in Autism
  29. Scott R. McConnell, 2002, Interventions to Facilitate Social Interaction for Young Children with Autism: Review of Available Research and Recommendations for Educational Intervention and Future Research
  30. Loveland K.A. & Landry S.H., 1986, Joint attention and language in autism and developmental language delay
  31. Wert B.Y. &Neisworth J.T, 2003. Effects of Video Self-Modeling on Spontaneous Requesting in Children with Autism
  32. Jones E.A & Carr E.G, Joint Attention in Children with Autism: Theory and Intervention, focus on autism and other developmental disabilities, Volume 19, number 1, Spring 2004
  33. NiritBauminger, Cory Shulman, The Development and Maintenance of Friendship in High-Functioning Children with Autism Maternal Perceptions, Autism7(1):81-97, April 2003
  34. Prothmann et. al, 2009,Preference for, and Responsiveness to, People, Dogs and Objects in Children with Autism
  35. Knott, et. al, 2006 Living with ASD
  36. Bellani, et. al, 2011, Virtual reality in autism: State of the art