AUTISM : CURRENT ISSUES 21

These notes begin with a further reference to the issue of the MMR vaccine, and the continuing evidence for no association between vaccine effects and autism or bowel disorder, although it appears that some doubts or anxieties still exist. Subsequently, there is a description of issues which may reduce the probability of full inclusion in a secondary school, coupled with a reiteration of the need for whole school approaches and individualisation of demands upon students with ASD. Finally, there is a description of research which examines the matter of theory of mind, and which highlights the significance of direction of gaze as a diagnostic indicator.

The concluding summary reiterates that there is no meaningful evidence to support a link between MMR and autism or bowel disease. There is, on the contrary, much evidence for the effectiveness and safety of MMR. It is the use of single vaccines which is untried and untested. It is recognised that parents should have the final say in this matter, but the advice from the current authors is that the evidence in favour of MMR is "overwhelmingly conclusive" so that health professionals should have no hesitation in recommending its use.

With particular regard to the issue of the alleged vulnerability of the young child's immune system, one might refer to the recent evidence cited in the national press (The Guardian 8 January 2002 : byline Sarah Boseley) that a baby's immune system could safely cope with many times the impact of the current MMR vaccine and there is no risk from the use of the combined vaccine.

The evidence in question comes from the journal Pediatrics (Offit et al 2002) and it is held that the immune systems of babies are capable of responding successfully to a vastly bigger challenge than the series of triple vaccinations. There is no support for any suggestion that multiple vaccines overwhelm or weaken the immune system. On the contrary, by providing protection against a number of bactcrial and viral pathogens, vaccines prevent any weakening of the immune system and subsequent secondary infections.

The authors argue that, from before birth, babies develop the ability to respond to a large number of antigens (molecules recognised by the immune system as foreign). They conclude that if multiple vaccines overwhelmed the immune system, it would be predicted that they would generate a less effective immune response in the child than when given singly; however, combinations such as MMR, or diptheria/tetanuslpertussis, give children as much immunity when given together as when given singly.

However, as indicated at the beginning of these notes, not everyone has been reassured by these findings, and there is a large number of court cases pending in the UK where families are alleging damage in their young children brought about by the MMR vaccine. Some medical professionals continue to express reservations or questions, including a criticism of the Finland study to the effect that over-reliance was placed upon doctors to inform the authorities when they thought that a child had experienced a serious and adverse reaction. This kind of passive surveillance may have led to an underestimate of difficulties, particularly as there was no suggestion about looking for symptoms of autistic spectrum disorder as side effects.

It is further noted that any reaction to MMR is not likely to be rapid or dramatic, but that regressive autism and bowel disorder are conditions which involve a slow process of degeneration, and the implication is that safety trials should have allowed a much longer time scale.

All this reinforces the diverging view (as expressed, for example, by Aarons and Gittens 1992) that, while a student may have excellent intellectual capabilities, one has to recognise the considerable and wide-ranging handicap that will result from the absence of social skills. As young people pass through adolescence, social interactions and the associated cues and rules, become increasingly complex and subtle, and a lack of "street-wisdom" represents a major limitation.

The implication is for ASD awareness-raising among peers and staff, and for specific efforts to teach or demonstrate social skills, and to provide opportunities to practise them in different settings, rather than assuming that these skills will develop automatically or incidentally. Children will not be "cured" of their ASD status, but one can organise the learning settings, set up social activities and club attendance during lunchtimes, and organise demands in such a way as to ensure that the needs can be accommodated and their effects minimised.

Further, Howlin (1988) argues that one might seek to include the children and young people in question by allowing time to work on their particular skills or interests, but this would involve a certain individualisation of the timetable. What matters is the willingness to recognise the probably uneven pattern of skills and abilities. A student may have high ability in music or maths or in any given area, and there may be an assumption that such skills will be matched by good or at least adequate skills in other areas, when, actually, this may not be the case. Problems may arise from inappropriate expectation.

In the same way, Taylor (1990) stresses that, whatever their level of ability, the young people with autism will continue to need direct teaching of a number of life and social skills which normally developing individuals will acquire unthinkingly simply as a result of increasing experience.

For example, she argues that these life skills underlying the ability to cope with day to day activities and routines are more important than any single academic skill. One must keep in mind that organisational ability, intuitive understanding of cause and effect, and the ability to make judgements, may be taken for granted in the majority of children and young people, but may be totally lacking among individuals with autism.

The students need to be taught what kind of behaviour causes problems in the classroom, and why; how to develop a greater social awareness; how to carry on a conversation; and the need to listen alongside talking and asking questions. In fact, repetitive questioning is seen as a common problem interfering with social acceptance and interaction.

This final section focuses upon a theoretical issue, exploring a particular aspect of theory of mind.

Ruffinan et al (2001) begin by reiterating that a weakness in theory of mind is a basic and defining characteristic among children with autistic spectrum disorder. However, they review a number of studies in which performance by control children on tasks of social understanding has been as impaired as that of children with autism.

In contrast, other research has used behavioural measures and has examined more general social understanding than simply theory of mind, and it is with this kind of study that the particular difficulties of the children with autism are most evident.

Such children tend not to look at others' faces in order to share attention, nor do they tend to engage in gaze monitoring.

There is also evidence that young children with autism can be differentiated from control children with moderate learning difficulties in terms of their being less distressed by facial expressions indicative of distress or anxiety; similarly, the way the ASD children examine objects may be characteristic, and they tend to look more at objects than people, and to shift attention from objects to people less frequently than controls.

The implication is for a lack of "social referencing" in the children with autism.

A study by Clements and Perner (1994) used a verbal question and eye gaze as a measure of false belief understanding. Children listened to a story in which a character (Sam) placed a toy in place X and then went away, at which point another character moved the toy to place Y. The children were then given a prompt like "I wonder where Sam will look for the toy", and the children's eye movements were videotaped throughout to see if they anticipated where Sam would look by shifting their gaze to the appropriate place in response to the prompt.

It was found that children's gaze revealed an earlier sensitivity to belief than did their explicit responses, indicative of implicit knowledge of false belief.

In their own study, these present authors explored the use of eye gaze in differentiating between children with autism and children with MLD. The theory goes that normally developing children have a basic understanding of the social world which is partially innate and partially a function of their experience and interest in observing other people. With time and increasing language, the children are able to gain a conscious and verbally-mediated theory of mind.

Children with autism, on the other hand, may understand the social world differently. There is little of the initial implicit understanding, and there is a greater dependence upon specific teaching rather than incidental learning.

Implicit knowledge may serve an important function in underlying communication even if the child cannot verbalise or even think explicitly about what he is observing. The example is given of a 12 month old baby placed on the edge of a visual cliff and who might proceed or stay put depending upon the expression on the mother's face. If the mother looks anxious, the baby will not move : if she looks happy, the baby will crawl on. The baby does not need to understand the mental state involved , or verbalise his own feelings; it is simply a matter of reacting appropriately to the behavioural expression of emotion.

The authors concluded that eye gaze probably measures unconscious but core insights into social behaviour and is a better means of highlighting this particular characteristic of the autistic child. It is also noted that the least efficient use of eye gaze was a valid indicator of the most severe form of autism.

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