Is Autism a “Public Health Crisis?”. Part 3
Chapter 3 of the Commission’s report goes on to reference the need for “all health plans to treat autism as a neurological condition…” in the same domain as “…stroke and other neurological conditions” (2007, p. 29). In fact, the constant reference to the supposed medically-based “symptoms” of ASD may mislead professionals and families into the misperception that there are immutable and stable characteristics of ASD which are predictable across persons with the diagnosis. If specific behavioral characteristics were stable symptoms across all with an ASD diagnosis, consistent diagnostics could be done and treatments selected that would be consistently effective and successful in all of the ASD diagnosed population.
Instead, the reality is that ASD often leads to multi-faceted and highly heterogeneous areas of disability which can impact children very differently (Szatmari et al., 1995; Walker et al., 2004). Persons with autism can be very different with regards to their levels of social and cognitive competence and behavioral functioning. Though persons with autism often share specific behavioral and cognitive characteristics with individuals with Down Syndrome and Fragile X (Heward, 2003), these similarities do not make them all one disability category. Like Down Syndrome and Fragile X, autism is a developmental disability with a neurological impact rather than a neurological condition or illness. ASD does not explicitly or consistently ‘cause’ specific symptoms in the same way as asthma is linked to wheezing or epilepsy to seizures. Instead, autism reflects an increased probability that certain clusters of typical and observable human behaviors may occur at differential levels of frequency and intensity as compared to the general population. But, even then, subsequent behaviors are based more on social, learning, and reinforcement history; context and environment; previous history and experiences; cultural and systemic values; individual temperament; and transactional relationships (Horner et al., 2002; Mandel & Novak, 2005) than either the autism or perceived ‘medical necessities.’ The constant referencing of ASD as an on-going medical and public health crisis is therefore highly problematic and counterproductive. In this author’s view, children and families would be much better served by a view of autism as a crisis of instruction and learning whereby environmental restructuring and family supports, along with behaviorally-based intervention and individualized instruction, would be prioritized. ASD is not a medical or psychiatric condition at all but a developmental disability (Heward, 2003). The fact that other developmental disabilities, such as Down Syndrome, Fragile X, and Cerebral Palsy, very often have specifically associated neurological, cardiac, and/or GI implications has not led to these disabilities being classified as a “neurological condition” or “public health crisis” or demands for comprehensive coverage by health plans. Nor have instructional, behavioral, and social supports for these disabilities been equated with medical ‘therapy’ as the Commission’s report broadly indicates they have been for persons with ASD.
Instructional practices based in a behavioral analytic model starting with early intervention are known and widely accepted as a method towards ameliorating behaviors which may manifest in persons with ASD and interfere with individual learning, social, and personal success. Effective early behavioral intervention and effective instruction includes a reduced need for modifications and more intensive intervention over time (Koegel & Koegel, 1998; Lerman, et al., 2004). Even the most effective instruction and structural modifications typically will not generate similar outcomes in true neurological conditions.