case study for a child with autism

• NeuroLaunch

Autism Case Studies: Real-Life Examples and Insights

• Understanding Autism Spectrum Disorder (ASD)
• NeuroLaunch editorial team
• August 11, 2024
• Leave a Comment

Table of Contents

Stepping into the shoes of individuals with autism spectrum disorder, case studies unlock a world of unique perspectives, challenges, and triumphs that reshape our understanding of neurodiversity. These real-life examples provide invaluable insights into the complex and diverse nature of autism, offering a window into the lives of those affected by this condition. By examining these case studies, we can gain a deeper appreciation for the experiences of individuals with autism and their families, as well as the various approaches to support and intervention that have proven effective.

Overview of Autism Spectrum Disorder and the Importance of Case Studies

Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by challenges in social communication, restricted interests, and repetitive behaviors. Understanding Autism: Meaning, Spectrum, and Beyond is crucial for both professionals and the general public. The spectrum nature of autism means that individuals can experience a wide range of symptoms and abilities, making each case unique.

The prevalence of autism has been steadily increasing over the past few decades, with current estimates suggesting that approximately 1 in 54 children in the United States are diagnosed with ASD. This increase in prevalence has led to a growing awareness of the condition and its impact on individuals, families, and society as a whole.

Case studies play a significant role in advancing our understanding of autism. They provide detailed accounts of individual experiences, allowing researchers, clinicians, and educators to gain insights into the diverse manifestations of ASD. These studies help bridge the gap between scientific research and real-world applications, offering valuable lessons that can inform treatment strategies and support systems.

Understanding Autism Case Studies

Autism case studies serve multiple purposes in the field of autism research and treatment. They offer a comprehensive look at an individual’s life, including their developmental history, challenges, strengths, and responses to various interventions. This holistic approach allows for a more nuanced understanding of autism that goes beyond statistical data or generalized descriptions.

Typically, autism case studies include information such as:

1. Developmental milestones and early signs of autism 2. Diagnostic process and assessment results 3. Family history and environmental factors 4. Specific challenges in areas like communication, social interaction, and behavior 5. Strengths and special interests 6. Educational experiences and accommodations 7. Therapeutic interventions and their outcomes 8. Social and emotional development 9. Family dynamics and support systems 10. Long-term outcomes and quality of life

By examining these various aspects, case studies contribute significantly to autism research and treatment. They help identify patterns and trends across different individuals, highlight effective interventions, and reveal areas that require further investigation. Moreover, case studies often inspire new research questions and hypotheses, driving the field forward.

Autism Case Study Examples: Early Childhood

Early childhood case studies are particularly valuable in understanding the early signs of autism and the impact of early intervention. Let’s explore two examples that illustrate different aspects of autism in young children.

Case Study 1: Early Diagnosis and Intervention

Sarah, a 2-year-old girl, was brought to a pediatrician by her parents who were concerned about her lack of eye contact and delayed speech. After a comprehensive evaluation, Sarah was diagnosed with autism at 26 months old. Her case study highlights the importance of early detection and intervention.

Key points from Sarah’s case: – Early signs included limited eye contact, no babbling by 12 months, and no words by 16 months – Comprehensive evaluation included developmental screening, autism-specific assessments, and observations of behavior – Early intervention program started at 27 months, focusing on speech therapy, occupational therapy, and applied behavior analysis (ABA) – Significant improvements observed in communication and social skills by age 4 – Ongoing support and therapy continued as Sarah transitioned to preschool

This case underscores the potential benefits of early diagnosis and intervention in autism, as discussed in Could Autism Be Cured? Exploring Current Research and Future Possibilities . While a cure may not be currently available, early intervention can significantly improve outcomes for children with autism.

Case Study 2: Challenges in Social Communication

Alex, a 4-year-old boy, was diagnosed with autism at age 3 after his preschool teacher noticed his difficulties in social interactions. His case study focuses on the challenges in social communication often experienced by children with autism.

Key aspects of Alex’s case: – Demonstrated advanced vocabulary and memory but struggled with back-and-forth conversations – Showed intense interest in trains but had difficulty engaging in imaginative play with peers – Experienced sensory sensitivities, particularly to loud noises and certain textures – Intervention focused on social skills training, sensory integration therapy, and parent coaching – Progress noted in turn-taking and initiating interactions with peers after six months of intervention

Alex’s case highlights the complex nature of social communication difficulties in autism and the potential for targeted interventions to support skill development.

Autism Case Study Examples: School-Age Children

As children with autism enter school age, new challenges and opportunities arise. The following case studies illustrate some common experiences of school-age children with autism.

Case Study 3: Academic Challenges and Accommodations

Emma, a 9-year-old girl with high-functioning autism, excelled in mathematics but struggled with reading comprehension and writing. Her case study focuses on the academic challenges faced by many children with autism and the accommodations that can support their learning.

Key elements of Emma’s case: – Demonstrated exceptional skills in mathematical calculations and pattern recognition – Struggled with understanding abstract concepts in literature and expressing ideas in writing – Experienced difficulty with time management and organization – Individualized Education Program (IEP) implemented, including accommodations such as extra time for assignments, use of graphic organizers, and assistive technology for writing – Regular collaboration between teachers, parents, and special education staff to monitor progress and adjust strategies

Emma’s case underscores the importance of recognizing both the strengths and challenges of students with autism and providing appropriate support to help them succeed academically.

Case Study 4: Behavioral Interventions in the Classroom

Michael, an 8-year-old boy with autism, exhibited challenging behaviors in the classroom, including frequent meltdowns and difficulty transitioning between activities. His case study explores the implementation of behavioral interventions in a school setting.

Highlights from Michael’s case: – Displayed strong visual-spatial skills but struggled with verbal instructions and changes in routine – Experienced sensory overload in noisy or crowded environments, leading to meltdowns – Behavioral intervention plan developed, including visual schedules, social stories, and a token economy system – Quiet space provided in the classroom for self-regulation – Teacher and staff training on autism and positive behavior support strategies – Significant reduction in meltdowns and improved ability to transition between activities after three months of consistent intervention

Michael’s case demonstrates the effectiveness of tailored behavioral interventions and environmental modifications in supporting students with autism in the classroom.

Autism Case Study Examples: Adolescents and Adults

As individuals with autism transition into adolescence and adulthood, they face unique challenges and opportunities. The following case studies provide insights into the experiences of older individuals on the autism spectrum.

Case Study 5: Transition to Adulthood and Employment

David, a 22-year-old man with autism, navigated the transition from high school to employment. His case study focuses on the challenges and successes experienced during this critical period.

Key aspects of David’s case: – Graduated from high school with strong academic performance in computer science – Struggled with social anxiety and executive functioning skills – Participated in a transition program focusing on job skills, independent living, and social skills – Secured an internship at a local tech company through a supported employment program – Benefited from workplace accommodations, including a quiet workspace and clear, written instructions – Successfully transitioned to full-time employment after six months of internship

David’s case highlights the importance of targeted support during the transition to adulthood and the potential for successful employment outcomes for individuals with autism. Inspiring Autism Success Stories: Journeys of Triumph and Transformation provides additional examples of individuals who have overcome challenges to achieve their goals.

Case Study 6: Relationships and Social Support

Olivia, a 28-year-old woman diagnosed with autism in adulthood, focused on building relationships and developing a support network. Her case study explores the social aspects of autism in adulthood.

Key elements of Olivia’s case: – Late diagnosis at age 25 provided clarity and understanding of lifelong social difficulties – Joined an autism support group and found a sense of community – Engaged in social skills training and cognitive-behavioral therapy to address anxiety – Developed strategies for navigating social situations in personal and professional contexts – Formed meaningful friendships within the autism community and beyond – Advocated for autism awareness and acceptance in her workplace

Olivia’s case underscores the ongoing importance of social support and skill development for adults with autism, as well as the potential for personal growth and advocacy.

Key Findings and Patterns Across Autism Case Studies

Examining multiple case studies reveals several common themes and patterns in the experiences of individuals with autism:

1. Diverse presentations: Each case study demonstrates the unique combination of strengths and challenges experienced by individuals with autism, reinforcing the notion of autism as a spectrum disorder.

2. Importance of early intervention: Cases involving early diagnosis and intervention often show more positive long-term outcomes, highlighting the critical nature of early support.

3. Individualized approaches: Successful interventions are typically tailored to the specific needs, interests, and strengths of each individual, rather than following a one-size-fits-all approach.

4. Ongoing support needs: Many individuals with autism benefit from continued support and accommodations throughout their lives, albeit in different forms as they age.

5. Potential for growth and achievement: Case studies frequently demonstrate significant progress and accomplishments when appropriate support and interventions are provided.

6. Impact of environment: The role of supportive families, educators, and communities is evident in many successful cases, underscoring the importance of creating autism-friendly environments.

7. Comorbid conditions: Many case studies reveal the presence of co-occurring conditions such as anxiety, ADHD, or sensory processing difficulties, highlighting the need for comprehensive care.

8. Importance of self-advocacy: As individuals with autism grow older, the ability to self-advocate and communicate their needs becomes increasingly important for their success and well-being.

Effective interventions and support strategies that emerge from these case studies include:

– Early, intensive behavioral interventions – Structured teaching methods (e.g., TEACCH) – Social skills training and peer-mediated interventions – Assistive technology and visual supports – Sensory integration therapies – Cognitive-behavioral therapy for anxiety and emotional regulation – Vocational training and supported employment programs – Parent and family education and support

The importance of individualized approaches in autism treatment cannot be overstated. What works for one person may not be effective for another, and interventions often need to be adjusted over time as an individual’s needs change. This personalized approach is crucial for maximizing outcomes and quality of life for individuals with autism.

Autism case studies provide invaluable insights into the lived experiences of individuals on the spectrum, offering a nuanced understanding that goes beyond clinical definitions or statistical data. Through these real-life examples, we gain a deeper appreciation for the challenges faced by individuals with autism and their families, as well as the potential for growth, achievement, and fulfillment.

The case studies explored in this article highlight several key points:

1. The diverse nature of autism spectrum disorder and the unique combination of strengths and challenges each individual experiences 2. The potential benefits of early diagnosis and intervention 3. The importance of tailored support and accommodations across different life stages 4. The ongoing need for understanding and acceptance of neurodiversity in society

As we look to the future, autism research and case studies will continue to play a crucial role in advancing our understanding of the condition and developing more effective interventions. Exploring Autism: Key Research Questions and Discussion Topics for In-Depth Understanding provides insight into some of the critical areas that researchers are currently investigating.

Future directions for autism research and case studies may include:

– Long-term follow-up studies to better understand outcomes across the lifespan – Exploration of the impact of various interventions on brain development and functioning – Investigation of the experiences of underrepresented groups within the autism community – Development and evaluation of new technologies to support individuals with autism – Examination of the economic and societal impacts of improved support for individuals with autism

As our understanding of autism continues to evolve, it is crucial that we maintain a commitment to supporting individuals on the spectrum and their families. By fostering acceptance, providing appropriate interventions, and creating inclusive environments, we can help ensure that individuals with autism have the opportunity to reach their full potential and lead fulfilling lives.

Autism for Dummies: A Comprehensive Guide to Understanding and Supporting Individuals on the Spectrum offers additional resources for those seeking to learn more about autism and how to support individuals on the spectrum.

In conclusion, autism case studies serve as powerful tools for understanding, empathy, and progress in the field of autism research and support. By continuing to share and learn from these individual stories, we can work towards a more inclusive and supportive world for all individuals on the autism spectrum.

References:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

2. Baio, J., Wiggins, L., Christensen, D. L., et al. (2018). Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years — Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2014. MMWR Surveillance Summaries, 67(6), 1-23. https://www.cdc.gov/mmwr/volumes/67/ss/ss6706a1.htm

3. Dawson, G., Rogers, S., Munson, J., et al. (2010). Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model. Pediatrics, 125(1), e17-e23.

4. Kasari, C., Gulsrud, A., Freeman, S., Paparella, T., & Hellemann, G. (2012). Longitudinal follow-up of children with autism receiving targeted interventions on joint attention and play. Journal of the American Academy of Child & Adolescent Psychiatry, 51(5), 487-495.

5. Landa, R. J. (2018). Efficacy of early interventions for infants and young children with, and at risk for, autism spectrum disorders. International Review of Psychiatry, 30(1), 25-39.

6. Lord, C., Brugha, T. S., Charman, T., et al. (2020). Autism spectrum disorder. Nature Reviews Disease Primers, 6(1), 1-23.

7. Magiati, I., Tay, X. W., & Howlin, P. (2014). Cognitive, language, social and behavioural outcomes in adults with autism spectrum disorders: A systematic review of longitudinal follow-up studies in adulthood. Clinical Psychology Review, 34(1), 73-86.

8. National Research Council. (2001). Educating children with autism. Washington, DC: National Academy Press.

9. Reichow, B., Hume, K., Barton, E. E., & Boyd, B. A. (2018). Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). Cochrane Database of Systematic Reviews, (5).

10. Roux, A. M., Shattuck, P. T., Cooper, B. P., Anderson, K. A., Wagner, M., & Narendorf, S. C. (2013). Postsecondary employment experiences among young adults with an autism spectrum disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 52(9), 931-939.

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

Save my name, email, and website in this browser for the next time I comment.

• Privacy Policy
• Terms of Service
• Cookie Policy

About NeuroLaunch

• Copyright Notice
• Accessibility Statement
• Advertise With Us
• Mental Health

Good Autism Practice Report: Case Studies

Good Autism Practice Case Studies File Download

Good Autism Practice Guidance: Case Studies

These case studies support our Good Autism Practice Guidance. There are 8 individual case studies which consider the impact of Good Autism Practice on autistic children and young people in Early Years, Schools and Post-16. Download all the case studies above. 

The Good Autism Practice Guidance: Full Report

The Full Report and Practitioner Guide presents eight principles of good autism practice. These summarise the ethos, values and practice that should inform inclusive education for all children and young people whilst specifying the distinctive knowledge, teaching approaches required. Eight principles are identified which are linked to the new Ofsted Framework, the SEND Code of Practice and the Teacher Standards. The Guide is designed to support staff in Early Years settings, Schools and Post-16 provision to develop effective practice. The case studies serve to illustrate the eight principles.

Explore all upcoming Autism Training from our Partners.

Find Your Local Training Partner

Search for your local training partner to enquire about upcoming Autism Training or to organise a session for your team.

Browse all the AET Training Content which can be offered by our Partners. 

Explore all Autism Education Trust Resources, from phase specific teaching tools to parent guidance and more.

Find out more about the Autism Education Trust and meet the team.

Explore our blog to discover discussions on good autism practice, exclusion, the four key areas of difference and more...

Webcast: Autism and ADHD

Deepen your understanding of autism and ADHD with Jill Harper-Hill, our topic expert in webcast number two of our Autism Insights series.

Why Autism is a Difference, not a Deficit

Watch our free video: promoting a wider understanding that autistic people have strengths and differences in three key areas of development.

Autism Re-Explained

This video offers an accessible and insightful introduction (or refresher) on autism, specifically tailored for education professionals. It’s packed...

Sign up to our newsletter

An official website of the United States government

Official websites use .gov A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

• Publications
• Account settings
• Advanced Search
• Journal List

A case study on the effect of light and colors in the built environment on autistic children’s behavior

Ashwini sunil nair, radhakrishnan shanthi priya, prashanthini rajagopal, chandramouli pradeepa, ramalingam senthil, samiappan dhanalakshmi, khin wee lai, xiaowei zuo.

• Author information
• Article notes
• Copyright and License information

Edited by: Fengyu Zhang, Global Clinical and Translational Research Institute, United States

Reviewed by: K. Kiruthiga, Hindustan University, India; Thirumaran Kesavaperumal, National Institute of Technology, India

*Correspondence: Radhakrishnan Shanthi Priya, [email protected]

Xiaowei Zuo, [email protected]

This article was submitted to Autism, a section of the journal Frontiers in Psychiatry

Received 2022 Sep 12; Accepted 2022 Nov 14; Collection date 2022.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

The importance of strategies and services by caregivers and family members substantially impact the psychological and emotional wellbeing of autistic children. The rapid research developments in clinical and non-clinical methods benefit the features of autistic children. Among various internal and external factors, the influence of the built environment also impacts the characteristics of autistic children. This study investigates primarily the psychological effect of light and colors on the mood and behavior of autistic children to identify the most favorable and preferred indoor lights and color shades.

A questionnaire survey was conducted at an autism center among autistic children and their parents. This study included autistic children aged between 6 and 16 (45 males, 42 females, mean age 8.7 years, standard deviation 2.3). Eighty-seven participants were involved in the survey to determine the sensory perceptions, intolerance, preferences, and sensitivities of children with an autism spectrum disorder toward colors and lighting. The margin of error at the statistical analysis’s 95% confidence level is ± 0.481.

As per this case report, the children have various color preferences and respond differently to different shades. Different hues have varying effects on autistic children, with many neutral tones and mellow shades proven to be autistic-friendly with their calming and soothing effect, while bright, bold, and intense colors are refreshing and stimulating. The stimulus of bright-lighting causes behavioral changes in autistic children prone to light sensitivity.

The insights gained from this interaction with parents and caretakers of autistic children could be helpful for designers to incorporate specific autistic-friendly design elements that make productive interior spaces. A complete understanding of the effect of factors like color and lighting on the learning ability and engagement of autistic children in an indoor environment is essential for designers and clinicians. The main findings of this study could be helpful for a designer and clinicians to address designing an autism-friendly built environment with a color palette and lighting scheme conducive to their wellbeing and to maximize their cognitive functioning.

Keywords: autistic children, cognitive functioning, wall colors, indoor lighting, built environment, behavioral changes

Introduction

A significant instance of pervasive development being witnessed throughout the globe is the complex neurodevelopment condition called autism spectrum disorder (ASD) which impacts behavior, communication, and social interaction ( 1 – 4 ). The scientific community has conducted several research studies in recent years to assess the incidence and prevalence of ASD ( 5 – 7 ). A significant increase in ASD could be globally recognized ( 8 – 10 ). India is a highly populated nation of about 1.3 billion families with children under 15, representing almost many inhabitants per a detailed clinical evaluation ( 11 , 12 ). More than two million individuals in India have been impacted by autism. This challenging observation has led to user-centric strategies, support and intervention services such as healthcare facilities, education support, and rehabilitation services to facilitate easy interaction and seamless social integration. The need to cater to the unique needs, preferences, requirements and challenges of autistic children has directed the efforts of designers toward considering these essential aspects while designing inclusive and empowering spaces for children on the autism spectrum ( 13 , 14 ). ASD is characterized by cognition, understanding, social behavior, and emotional expression. People with autism have challenges deciphering emotional expressions, cannot comprehend the emotions of others, avoid eye contact, and have extreme sensitivity to the environment. Such sights or sounds could influence a positive change and behavior ( 15 ). Research studies have shown that the ASD group demonstrated greater perceptual and learning characteristics ( 16 – 18 ). Challenging features of executive functioning are commonly observed in people experiencing ASD, with noticeable suppression of cognitive flexibility; such behavioral inflexibility impacts their ability to perform any task ( 19 ).

Autistic children tend to perceive and experience their environment differently from others ( 20 , 21 ). By paying attention to the sensory sensitivities and challenges with visual information processing faced by autistic children, appropriate changes can be incorporated into their indoor environment to turn it into a friendly and accommodative place tailored to their unique needs. Suggestions were made optional but solicited to understand the user’s needs before designing an inclusive space for autistic children. This calming environment would encourage their growth and facilitate their learning regarding the visual environment and other influencing factors. The survey method provided valuable insights into the preliminary considerations for designing an engaging and welcoming indoor environment that provides positive sensory experiences and alleviates anxiety.

Any autism-friendly design depends first and foremost on the end-user’s unique needs, preferences, and comfort. The design considerations for sensory-friendly spaces must be based on the core aspects of functionality, connectivity and responsiveness following a careful study of the inherent features of the built environment and after gaining a good understanding of the unique perspectives of autistic individuals ( 22 ). Design mechanisms must also thoroughly examine essential factors such as imagination, verbal/non-verbal communication, social interaction, sensory issues, behavior, and safety. There continue to be several research studies on the many facets of autism, resulting in various scientific advancements and noteworthy developments. However, evidence shows that many factors remain unknown. Cognitive deficits and motor coordination challenges are common in children with autism. They have a detrimental impact on children’s everyday lives and limit their achievements. Due to the increased effort in caring for autistic children and finding ways to cope with their behavioral challenges, parents should be familiar with the environmental impacts ( 23 , 24 ). Autistic children tend to have a dysfunctional sensory system; this sensory processing disorder is perceived as the biggest challenge to surmount ( 25 , 26 ). Few but well-chosen articles and publications provide valuable insights into all aspects of one vital concept: the senses.

Information comes through all the senses, which are processed and organized by the brain. Processing sensory information is extremely difficult for autistic children, affecting their sensory responsiveness and reactions. Human senses are interconnected and cannot be separated, but multisensory integration is challenging for autistic children. The eight sensory systems are visual, auditory, olfactory, gustatory, tactile, proprioceptive, vestibular, and interoception. These are highly central to understanding sensory processing in autism and a sensory integration approach would make them very relevant to investigating visual processing ( 27 – 29 ). Sensory processing disorder is often a comorbid symptom of ASD, but not all children with sensory processing disorder have autism.

According to the literature, sensory difficulties and processing disorders appear to be more prevalent in autistic children and ASD is perceived to be the root cause of their sensory system ( 30 ). People with sensory processing disorders are generally classified as hypo and hypersensitive (under and over-responsiveness). The response and reaction of both categories to low and high stimuli in any setting tend to differ based on how they process sensory information. Individuals with autism are frequently more socially aware due to sensory difficulties with seeing, hearing, and feeling. Children with autism do not interact much with others, struggle with sensory overload, have difficulty expressing their feelings, and prefer to live in their private world of self-imposed isolation. Despite social, behavioral and communication challenges and sensory processing challenges, they have a strong understanding of their surroundings, have exceptional memories, are very creative and possess the ability to learn new skills ( 31 ). Thus, sensory integration issues can continually make the built environment unpleasant and hostile for many people on the autism spectrum.

Since ASD impairments can fluctuate between moderate and severe with few or mild characteristics and with co-occurring conditions, the abilities, needs and services demand to vary wildly across individuals. However, almost all require therapeutic interventions and support for their lifespan ( 32 ). Apart from a functional link with human health, emotions influence individuals’ interactions with environmental factors. In the long run, the features arising from misguided attempts to “regularize” the perception of an autistic individual may prompt corrective behavioral responses such as repeated motions and other methods to regain some predictability in sensory inputs. Free and open communication is essential because it affects how one understands, investigates, and evaluates surroundings ( 33 ). The emotional responses that arise throughout the relationship between a human and the different ecosystem entities might align with the earlier statement ( 34 ). Much clinical evidence is available in the Indian setting on ASD. The active involvement and participation of parents of children and young adults in intervention, integration, and rehabilitation efforts help in gaining a better understanding of autistic behavior, which is essential for all productive experimentation with the goal of better developmental, behavioral, and educational outcomes ( 35 ).

Many researchers have investigated the relationship between the five senses and their impact on the surrounding environment with multiple parameters. Investigating the quality and dynamics of early encounters is a difficult task. It usually necessitates observing and integrating multimodal social signals and comprehending how two interactions synchronize for understanding the autistic child’s behavior ( 36 , 37 ). Such understanding can significantly help designers design a supportive, autism-friendly environment and help them innovate in the design considerations of various inclusive spaces. Researchers have experimented, analyzed and briefly explained specific design considerations, elements and components for users on the autistic spectrum. The following design components help to understand the importance and need for a unique, autistic-friendly built environment for preliminary studies.

Space organization

The spatial element is a crucial factor that designers and architects must be aware of when building for people with ASD. This is attributed to the importance of routine, order, regularity, and predictability. Well-defined areas should be placed in a logical sequence based on the regular schedule followed in specific settings regarding spatial sequencing to make it easier for autistic children to navigate these spaces without assistance. A research study was conducted to recommend the setting up of an organized space focusing on accessibility to and inclusivity of autistic children by creating surroundings that were clearly defined, orderly, simple, safe, satisfying, predictable, welcoming, and stable ( 38 – 40 ). Spatial experiences are a method of using spatial knowledge to decode the arrangement of built spaces. A research study provided an overview of the Faison School in the United States. It demonstrated how adaptable and customizable layouts with sensory benefits could benefit autistic children with a sensory processing disorder. Introducing clearly defined strips along corridors is a component of spatial sequence and navigation aids that make indoor spaces reachable, inviting, and comfortable for autistics. The color of those strips is also crucial in the case of spatial navigation and when wayfinding techniques are deployed.

This technique develops a simple and easy navigational approach by incorporating assistive visual aids such as landmarks, decoration, and color-coding ( 32 ). Environmental navigation, orientation, and wayfinding were explored in a research study conducted in a school for autistic children ( 34 ). Before the study, the researcher spent time in the participants’ classrooms to become better acquainted with the users’ everyday routines and observe their behaviors and interactions during class activities, which helped frame their actions during wayfinding tasks ( 41 , 42 ). Various metrics were employed in evidence-based research to examine the effects of spatial navigational aids and the setting up of demarcated sensory-friendly zones such as sensory rooms. Children with sensory sensitivities could use it as a safe place to withdraw or shelter when overwhelmed by a sensory overload. A simple navigation system can help visually sensitive autistic users traverse their environment quickly and without fear. Color-coded paths can help them easily navigate from one location to another ( 43 ).

The importance of good lighting, both natural and artificial, is evident in the way it can transform any space. Lighting has a significant impact on the sensory system of autistic children. Evidence-based research was conducted on an active group of autistic users to determine their responses to lighting, their light sensitivity and possible light modifications that could be implemented for people with sensory challenges ( 44 , 45 ). The diffusive light effects on the walls were thoroughly studied through windows, floors, ceilings, and furniture. The study analyzed how the users reacted to light in the hallway when the change in hue caused corresponding changes in users’ behavior and mood. The study also explored adjustable lighting settings to match the natural circadian cycle of the body closely. Indirect lighting reduces flickering, intensity, and brightness, helping ASD individuals cope with their light sensitivity ( 38 ). Artificial lights should ideally be fitted with dimming controls to alter or produce a luminous interior as an indirect light source ( 13 ). Before the research observation of the study group of autistic children began each morning, a checklist was implemented to validate the accurate establishment of the route and to verify if the circumstances between the participants were consistent, remarkably everyday sensory stimuli like light and sound. To verify if circumstances between the participants are consistent, particularly considering light and sound, potentially observe autistic children.

Based on the environmental conditions, the responses gathered included the children’s reactions to light (amount of illumination) and sound (number of decibels), which were studied to devise ways to help autistic children struggling with sound and light sensitivity. Ideally, the environmental circumstances should be constant for all participants, especially since bright lights and loud sounds can be bothersome sensory overloads to autistic children affecting their functioning and behavior. The restriction of visual stimulation was enforced through dimmer switches provided for all lighting installations to reduce light levels based on the need ( 46 ). Students could easily regulate the degree and intensity of light stimulation by switching each light row as needed.

Sound quality is perhaps the most critical component in managing and maintaining autism spectrum conduct on an even keel among all the visual inputs involved in building design ( 47 ). Therefore, attempts must be made to reduce the auditory sensitivity of autistic children and prevent sensory overload. An experiential study showed that lowering sound levels and echoes in zones packed with autistic students resulted in improved mental attentiveness, service quality, a better quality of work, and reduced the tempo of compulsive self-stimulating behavior ( 32 ). The authors indicated that due to the intolerance of extraneous noise and difficulties in auditory processing, auditory sensitivity measures while planning interior acoustics are essential for building environments housing people with autism. Therefore, architects must avoid excessive ambient noise and effectively manage the acoustic requirements of enclosed spaces to prevent the extra stimulation from a noisy space that could distress autistic children with sound sensitivity in a space.

By identifying and eliminating interfering sensory information under the user’s needs and creating a quiet and comfortable environment conducive to productivity, people with autism can enhance their attention, reduce stress, and prevent inappropriate behavior. The authors advised the integration of pink cacophony for privacy and a salutogenic sound design approach in a space with many activities. A lower sound intensity of less than 50 dB is preferable for autistic children and beyond 60 dB makes it inappropriate. It was also recommended that a suitable acoustic environment within an enclosed space by reducing the frequency of the room’s resonance for acoustic comfort and soundproofing a room by ensuring good sound absorption.

Autistic children are sensitive to colors depending on how they perceive them. Most see them with greater intensity than they are. Colors in interior spaces affect their mood, learning, and behavior and must be chosen judiciously ( 42 , 43 ). Colorful mat boards were chosen in a research study to make color shapes on the floor as the lightweight material was not a potential hazard. It was ensured that their color complimented the aids placed by the door to establish a uniform color pattern. The colored indicators, colored doors, and floor forms enabled traceability and consistency. The study’s findings revealed that colorful signs made areas more accessible and easier to navigate for autistic children. Using autism-friendly color palettes such as pastel shades, neutral colors, and muted tones can foster a soothing sensory experience in an indoor environment. Bold and bright colors must be avoided as they could be over-stimulating and disturbing, which may cause autistic children to become tense and aggressive. Autistic children keenly feel different from others due to a lack of self-confidence and an inability to adapt. The importance of using color therapy to assist and empower autistic children to function without discomfort in a calm environment and in correcting their behavioral abnormalities must be recognized ( 48 ).

Investigations are necessary to examine the impact of color indices on learning specific complex tasks. Thus, the variable effect of indices on generalization and persistence is mainly in the case of color formation. Investigations are necessary to examine the psychological impact and effects of color on learning specific complex tasks and cognitive task performance by autistic children. Evidently, with the understanding of the existing scenario and the available data, it seems worth examining the application of color techniques for autistic individuals ( 49 ). Using organic material and neutral and relaxing color tones is deemed suitable for an autistic educational environment as they are conducive to learning, increase attention and boost energy levels. Psychological features are practical with selective colors. Red or yellow can be problematic as they can agitate, depress or confuse autistic children causing their withdrawal ( 13 ). An uncommon experimental study was conducted to determine if concepts could be taught to autistic children by associating them with color ( 50 ). The authors attempted to explain an inclination model simply by associating colors with symmetrical items objects ( 51 – 53 ).

People pick colors linked to things they like and do not prefer the colors they dislike ( 54 ). Autistic children generally have atypical color preferences and aversions with complex emotional associations with color ( 55 , 56 ). Their visual perceptions of color can influence their emotions and behavior ( 57 – 60 ). High contrast choices by participants with ASD may be due to color compulsions and may be attributed to a preference for items in colors they like. A study of participants with ASD found that color preferences and obsessions could be linked to a preferred object, resulting in higher color preference than usual ( 50 ).

Protecting autistic children from harm by providing a safe and secure environment is vital as their sensory processing ability is not developed enough to recognize challenges and handle crises ( 13 ). As children with autism often prefer to flee and escape frightening situations, it is necessary to establish standard procedures or safety systems that make it impossible for them to leave any place unnoticed places or amenities. Generally, any place’s structure, organization, and design must be ensured that it offers maximum freedom and flexibility, eliminates all problematic situations, addresses safety concerns, and is tailored to the behavioral factors unique to ASD users. Although all possible chances cannot be eliminated, they must be anticipated; safety issues must be duly considered, and safety strategies must be customized, as ASD children are susceptible to many challenges. Integrating primary entry points of safety systems enables the monitoring and tracking of the movement of people. For example, establishing exterior barriers improves safety aspects and facilities better organization, particularly in open spaces and courts. Installing mirrors with rounded corners in restrooms, using reflectors and fixing wider toilets are simple and easy measures that can be adopted to make areas safe, comfortable, easily accessible, and autism-friendly zones.

In most research studies, the preferences and opinions of autistic people are kept for analysis at a later stage. Several studies have highlighted the importance of clear rules, consistent routines, and calm orderliness for the adaptive functioning of individuals with ASD. Such studies are to help them cope with a predictable environment, situation, or setting without unexpected changes and help them to be engaged without being overwhelmed by anxiety ( 61 , 62 ). As they face language difficulties and communication challenges, schedules and structure are very important as they provide much-needed stability and help improve their wellbeing.

Many behavioral changes are attributed to different colors, and many research studies have attempted to decode the physiological effects of colors observed in autistic people. A study found that the strategic use of color could foster learning and suggested that the materials for learning activities could be chosen based on favorable color perceptions ( 63 ). The fixtures and furnishings provided in an enclosed space also play a crucial role in the sensory experiences of an autistic person while transitioning from one space to another. Loud and noisy disturbances are usually not tolerated by autistic individuals as they have auditory sensitivity. These jarring stimulants can serve as triggers and bring about behavior changes ranging from mild to severe. Surveys on autistic users have provided an exceptional understanding of how they perceive space and spatial relations.

Many diverse research studies conducted by various scholars have extensively investigated the fundamental aspects relevant to enabling an autism-friendly environment ( 50 ). However, the core concepts of color, light and texture, all fundamental design aspects, must be linked to the essential components of visual and tactile sensory learning. These interconnected factors can provide an enriching experience for autistic individuals when they are integrated. Not many quantitative research studies have explored creating an independent, sensory-friendly environment for autistic individuals. The initial findings of some research studies have indicated that design elements such as color, light, and texture must be studied collectively. Determining the combined influence of color, light, and texture on interior spaces makes them more accommodating for autistic people with sensory intolerance. The perception of psychological changes, emotional expressions, and behavioral alterations in autistic children could be studied further to enhance their features.

Although several diseases fall under the gambit of ASD, this study focuses on autistic children’s visual sensitivity. The understanding of the sensory perceptions of ordinary people is evident. Understanding the sensory perceptions of ASD people are challenging to determine their human psychology toward colors and lights. The novelty of the present study is a non-clinical approach to identifying the favorable visual environment for ASD children using interaction with the parents and caretakers of children with ASD. The indoor domestic environment has been critically investigated to determine if it is conducive to the unique needs and requirements of the children. Many environmental circumstances can affect the behavior, learning, performance, functioning, and wellbeing of autistic children, such as sound, smell, temperature, sense perceptions, communication, and social interactions. This investigative study is limited to the influence and impact of the two crucial sensory factors of light and color on autistic children in addition to space, wayfinding, and acoustics. This case study is primarily aimed at improving the quality of life of children with ASD through architectural aspects of the indoor built environment.

The present study examines the sensory impact of light and color in an indoor environment on autistic children whose senses are generally more heightened than usual. The insights on sensory triggers gained from this study can guide designers and clinicians while designing living spaces and taking steps to reduce stimuli that may lead to behavioral features. Understanding ASD is difficult due to neurological abnormality and a complex behaviorally defined development disorder with multiple contributing factors. With the increasing prevalence of autism worldwide, the need for progressive architectural design standards, guidelines and best practices to improve the built environment, explicitly incorporating sensory sensitivity strategies in interior spaces that cater to autistic requirements, is being keenly felt. There is greater recognition for design’s impact in providing a soothing yet engaging environment for children with special needs. The primary objective is to share the fundamental factors to be considered in an indoor space and the tools and techniques that can be deployed to transform it into a calm, supportive, and autism-friendly zone, thereby resolving several adaptive issues for autistic children.

The primary objectives of the present study are as follows:

Identify the central impairments of sensory intolerance in autism and understand the functional impact of light and color on autistic children.

To provide a pleasant sensory experience of light and color to make them feel safe and secure within the built environment.

Investigate the perception of light and color by autistic children and their influence through a comprehensive survey with various parameters.

The current work is summarized in the following sections. Section 1 provides the background and needs of the present study. Section 2 elaborates on the methods adopted in this case study. Section 3 discusses the results of the case study. Section 4 describes the discussion of the results. Section 5 summarizes the significant conclusions and further scope of the research.

Materials and methods

Data collection.

The research commenced with an in-depth literature review carried out in an organized manner to identify the current knowledge and understanding of ASD before framing the questionnaire contents ( 64 – 66 ). The questionnaire survey for the quantitative analysis consisted of forty questions that comprehensively covered the primary design aspects that need to be considered, in terms of light and color perceptions, before designing interior spaces intended for autistic children. The questionnaire was carefully designed in a lucid and straightforward format from the literature ( 67 – 73 ). The questionnaire was fine-tuned further in consultation with the therapists. The questionnaire survey was followed by ranking to indicate the category of the factor under consideration: low (Not at all suitable–one-point scale, suitable–two-point scale)–moderate (neutral–three-point scale), high (Most suitable), not necessarily essential. All the research questions in the questionnaire had this scale as a ranking guide. Figure 1A shows the various parameters used for the questionnaire of the present study. Figure 1B illustrates the color matrix used to understand user preferences and behavior.

(A) Parameters used for framing the questionnaire of the present study, (B) color matrix prepared to understand user preferences and behavior.

The questionnaire survey was conducted with the parents of autistic children in-person mode. Informed consent was obtained from the participants before the interaction. The data was collected manually from Autism Schools in Northern India. Responses were collected from parents and caretakers of autistic children by conducting a structured interview per the prepared questionnaire. The data collected was then statistically analyzed and interpreted the results. The survey was first conducted with eighty-seven participants, all parents, and caretakers of children with autism.

Prior to commencing the interview, parents were briefed about the purpose of the research study, its envisaged contribution and its importance. The parents and caretakers were notified about the survey’s objectives and informed of the importance of the questionnaire survey. The main intention of the questionnaire was to understand the sensory preferences of autistic children in an indoor environment regarding light and color factors.

The questionnaire was divided into three sections, details of which are as follows.

Section A comprises the names of the parents or the therapist/psychologist, the child’s age, gender and city of residence.

Section B includes open-ended questions about artificial and daylight conditions, window position, lighting position, the color of lights, degree of brightness, light color temperature, and favorable behavioral changes that can be brought about by altering lighting conditions.

Section C presents a color matrix. The child or the parent picks up the color of their choice based on parameters for gauging the children’s mood, whether they feel comfortable, uncomfortable, calm, and patient, or disturbed. Colors are chosen for different rooms and preferences are noted to determine autism-friendly colors. Section C also comprises generic questions regarding preferences for sensory dimensions of space and the importance of visual stimuli in providing favorable sensory experiences.

To gain an understanding of the behavior of autistic children, the survey was conducted based on Section A, comprising of age, gender, and city of residence of the study participants. For this survey, eighty-seven participants were considered, amongst which 45 were male and 42 were female. Section B comprises a comprehensive questionnaire to determine the impact of light on autistic children. Table 1 shows the statistical analysis of the selected participants.

The statistical analysis of the selected population of 87 participants.

Appendix A provides insights into the section comprising three parts where the focus group is mainly children falling into the age group of 6–16 years, with the overall count being eighty-seven participants. The survey was conducted at autism centers under a professional practitioner’s guidance.

The analysis and the questionnaire survey findings are presented in this section with sub-sections for light and color, respectively. The standard deviation of the survey method is 2.3. The margin of error and coefficient of variation at a 95% confidence level is ± 0.85 and 0.27, respectively. This confirms that the results are within the permissible values.

Analysis of light

Figures 2 – 4 reveal that, in most cases, autistic children did not prefer to have too harsh lights, fluorescent tubes, bright lights, below-eye-level window positions, flickering lights, dark lights, and dark spaces. Children felt flustered in low light conditions and had difficulty perceiving the environment in most cases. Flickering fluorescent lights were to be avoided as they were a stress-producing factor that made the children feel agitated and uncomfortable. Autistic children are extremely sensitive to the sub-visible flicker of direct fluorescent lighting, which can hurt their eyes and cause headaches. Ideally, all lights must be easy to use and come with a control switch so that children can alter the intensity of lighting fixtures, and dim or brighten them, to suit their visual needs. Neutral lighting can calm and soothe children by fostering a relaxing environment. Ideally, lights must be task-specific and based on the circumstances and conditions of the indoor space. Proper lighting design is essential as people with ASD have a heightened response to sensory inputs. According to the survey, direct lighting should be present in rooms, but intense light or glare must be avoided, and natural daylight is preferable in as many places as possible.

(A) Artificial lighting conditions, (B) natural light conditions.

(A) Feasibility of autistic children under various lighting conditions, (B) preferable position of the light, (C) preferable position of window placement.

(A) The behavior of autistic children under low light conditions, (B) preferable light bulb for autistic children.

Sunscreen can be provided as it can be a convenient option for autistic children who want to block out direct light diffusion. The communication and behavior of the children were observed when they were studying under low light conditions to determine if they were calm and focused or agitated and irritable to identify an autism-friendly lighting arrangement. In most of the cases, it was observed from the survey that the children had difficulty with language activities that involved reading. They struggled with words and quickly got flustered. Autistic children have characteristics with the visual perception of the environment, tend to lose concentration, and have learning difficulties. A combination of factors considered in the study may be needed to better understand their behavior within an enclosed space. This is because autism is a complex spectrum disorder with a broad range of conditions and features that differ vastly from person to person.

Analysis of colors

When conducting the survey, it was observed that most parents wanted a designated sensory space to provide an immersive sensory experience for their children. A sensory space is a specially designed and personalized therapeutic area with many sensory-friendly objects that autistic children are familiar with, which can be explored with the senses and are in different color palettes and textures. This space is designed to provide a calm and relaxing area for autistic children with sensory processing challenges to slowly habituate themselves to the visual and tactile environment. The survey reveals that it is critical to consider visual aspects at the preliminary design stage to ensure a good balance of visual elements and features in the built environment to make it a safe, secure, accessible, appealing, and comfortable for autistic children. Figure 5 illustrates the color analysis of the survey done using the color matrix.

Illustration of color analysis from the survey done by the color matrix.

A color-related questionnaire is handed out to the participants to determine color preferences; it is found that the most suitable colors are pastel, dull, neutral, and muted shades that are not distracting but have a tranquil effect. The chosen color scheme must accommodate visual sensitivity is of prime consideration for autistic children with sensory processing disorder as it can affect their mood, learning ability, and function. The darker shades are deemed to be unsuitable. The least preferred colors cause extreme behavioral changes like agitation, irritability, confusion, distress, anger, and aggressiveness.

The interaction of light and color is observed in this survey as their physiological effects can positively impact an autistic child. The variables defined in the table for studying the impact of light create an understanding of whether artificial lights, LED, dimmable, and incandescent bulbs are preferable depending on their effect on the sensitive eyes of autistic children ( 74 – 80 ). The most preferred light position is overhead, as there is no direct eye-level visibility to any artificial lights. Light visibility can be minimal to the user if the lights are flushed in the ceiling or when a false ceiling is provided. The relation of light with color and vice-versa is critical. They do not work in isolation; they work together. Both these factors combine to play an essential role in the built environment. Social contexts and family care are also essential to better servicing autistic children ( 81 – 87 ). Ensuring illumination comfort for autistic children by designing spaces that consider their light sensitivity is essential. The surveys conducted on autistic users offer an exceptional understanding of how they perceive color and react to it with their unusual sensory processing. This study contributes to identifying the initial set of design parameters that must be considered in an indoor environment to meet the needs of autistic children.

Impact of lights

On examination of the various lighting conditions, a dark room, darker lights, and more brightness are not preferred. Natural daylight is perceived to be the best lighting for indoor spaces. Fluorescent lamps are suitable if they have the option for the brightness levels to be controlled. Neutral-colored lights are the preferred option. Most participants prefer LED lights over fluorescent lights as the harsh light from the latter tends to cause agitated behavior and extreme distress in autistic children with light sensitivity.

Another component of lighting conditions within enclosed spaces must be considered the light’s and window’s positions. Autistic children can be oversensitive or under-sensitive to bright lights, which can debilitate their functioning; strategic light and window placements can help minimize the light intensity and provide a calm and relaxed work or play environment. The overhead lights option is preferable to avoid direct light visibility, and desk lights are another option. It is observed that in most cases, the window is situated at or directly above eye level. Windows at higher levels are not preferred. The study also included the color and temperature of lighting applications while determining the light efficacy factor as they tend to psychologically impact all humans, particularly autistic children with heightened sensory sensitivity. This becomes important as there is a definite connection between lighting and behavior, as evident from behavioral changes noticed in autistic children who become aggressive and flustered if they are not comfortable with the illumination provided by the lighting arrangements. Subtle manipulation of lighting can alter the mood, behavior, and perception of autistic children. Light color, source, quality, direction, and intensity are aspects to be considered in providing an optimally lighted environment that considers the light sensitivity of its inhabitants.

Impacts of colors

A questionnaire survey method investigates the visual aspects that significantly influence a space. According to the study, it is noted that children have a broad range of color preferences and respond distinctively and differently to various shades showing the importance of using an ASD-friendly color palette. Light, color, and space are essential components of any indoor environment that must be considered when designing for children on the autism spectrum. Architecture, as a profession, uses best design practices to devise customized environments which are engaging spaces that fulfill the specific needs of individuals, help them cope with their surroundings, encourage their independence, and positively impact their performance and behavior. In this regard, with greater recognition of effective space design’s impact on individuals with autism, designers and clinicians can consider indoor environmental aspects at the primary level and research the same issue with other interlinked factors. This study is one kind to facilitate a macroenvironment that can promote clinical services for autistic children. These results help determine the external factors that could enhance the abilities and functioning of autistic children in the built environment.

According to the survey results, light and color are significant variables within a built environment that greatly influence autistic children as they have a sensory processing disorder. Among the selected variables, light and color strongly correlate with the behavior of ASD children when compared to space and wayfinding. The results of the present study are on par with the literature ( 88 – 93 ). Every autistic individual is unique; each person reacts differently to the environment and sensory stimuli besides having individual preferences and aversions. As per the study, they have many color preferences and respond differently to different colors. Colors and light can be effectively deployed to bring about some desired positivity and social and behavioral change. The light sensitivity factor deals with the difficulty of sensory overload and requires further research on light rendering and acoustics. Such architectural aspects of the built environment also favor dealing with the characteristics of autistic children in addition to other clinical and non-clinical methods and techniques.

Limitations of this case study

The number of participants involved in the present study produces substantial input to the architects and clinicians. However, further studies with all stakeholders with more populations and their interactions are necessitated to improve the built environment designs more refined for autistic children. This study is mainly focusing on the non-clinical survey approach. However, the clinical and non-clinical approaches, like measuring heart rate, speech, language skills, emotions, social interactions, other motor, and non-motor skills could produce more appropriate solutions. Further clinical studies are required to expand the demography to improve autistic-friendly built environments and designs to assist the efficiency of the support and services to autistic children. The present study’s results are mainly pertinent to design an autistic-friendly built environment on a non-clinical approach using a questionnaire survey. Thus, further non-clinical and clinical studies on several micro factors are required to expand this survey to autistic adults.

The effects of light and color on the behavior of autistic children were investigated using a questionnaire survey. The full involvement of all the users was critical from the commencement to the completion of the survey. The study shows that dialogues were substantially reshaped during the color matrix questionnaire. The findings were obtained through cost-effective non-clinical methods. This was crucial from the start, as most research studies on ASD offer unclear and hypothetical results. Therapists, parents, and children actively participated in the survey sessions and offered valuable insights to designers and clinicians. The therapists and parents are vital users closely involved in meeting the needs and demands of the children under their care. Their experiences with the children offer essential data that helps understand the likes and dislikes of autistic children in the built environment regarding the lights and colors. The major conclusions of the present study are as follows.

The standard deviation of the survey method is 2.3. The margin of error and coefficient of variation at a 95% confidence level is ± 0.85 and 0.27, respectively. This confirms that the results are reasonably within acceptable limits.

The literary assessment and survey were utilized to comprehend the effect of colors and light in any indoor environment for children with autism.

The lights and colors of indoor environments are the most influencing factors in promoting the harmony of autistic children compared to space and wayfinding.

Direct lighting and natural daylighting are preferable to intense light or glare in as many places as possible.

The spaces designed for people with ASD must address how these people perceive the environment and react to space features.

The study proves that dull and pastel colors and muted lights are more suitable for visually sensitive autistic children.

Lower sound levels of below 50 dB are autistic-friendly, and beyond 60 dB develops inappropriate behaviors.

Light, color, and space are preliminary considerations of any inhabited environment. There is an increased need to ensure the suitability of light and color provisions in all interior spaces intended for autistic children to make them sensory-friendly. These findings emphasize the need to understand the different parameters associated with autistic users and the benefits of designing an autistic-friendly environment.

Designers should look upon these three variables effectively for comprehensive design and further studies. By recognizing the influence of the sensory environment on autistic behavior, designers should consider these critical variables and adopt a sensory-sensitive approach to design inclusive spaces with optimum comfort. The current findings emphasize the need to understand the different sensory issues and parameters associated with autistic users and the importance of design considerations required for setting up an accommodative, supportive, neurodiverse, and autistic-friendly environment tailored to their need for positive sensory experiences. Thus, the present analysis and the scope for further research studies could benefit autistic individuals by appropriately analyzing the selective blended clinical and non-clinical techniques.

Data availability statement

The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.

Ethics statement

Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.

Author contributions

AN, RP, and PR contributed to the study’s conceptualization, design, and investigation. CP, RS, and SD critically verified the data and analyzed. KL, XW, and XZ contributed to the data analysis and revision of subsequent versions. All authors contributed to the article and approved the submitted version.

Appendix-1 Questionnaire

• section a.

What is the age of child?

Which city is the child and family living?

What is the gender of the child?

• Section B

Impact of light on autistic children.

Parameter 1.0

How suitable is the following artificial lighting conditions for your ward? [Fluorescent tubes].

How suitable is the following artificial lighting conditions for your ward? [Normal bulbs].

How suitable is the following artificial lighting conditions for your ward? [The light is not bright].

How suitable is the following artificial lighting conditions for your ward? [The light is bright].

How suitable is the following artificial lighting conditions for your ward? [The light does not flicker].

How suitable is the following artificial lighting conditions for your ward? [They can dim the light by themselves (brighter/darker)].

How suitable is the following artificial lighting conditions for your ward? [Generally, they do not like artificial lighting].

Parameter 2.0

How suitable is the following natural daylight conditions for your ward? [There is No direct light into the room].

How suitable is the following natural daylight conditions for your ward? [The light is not bright].

How suitable is the following natural daylight conditions for your ward? [The light is bright].

How suitable is the following natural daylight conditions for your ward? [They have the possibility to close the sun screening device].

How suitable is the following natural daylight conditions for your ward? [Generally, do not like daylighting].

Parameter 3.0

Select the options that describe how your ward behaves when exposed to low light conditions.

Parameter 4.0

How suitable is the following lighting conditions for your ward? [Neutral Light].

How suitable is the following lighting conditions for your ward? [Much of bright light].

How suitable is the following lighting conditions for your ward? [Preferably a little bit darker light].

Parameter 5.0

How suitable is the following lighting conditions for your ward? [Totally dark room].

Parameter 6.0

How suitable is the following lighting conditions for your ward? [Feels comfortable under all lighting conditions].

Parameter 7.0

How suitable is the following lighting conditions for your ward? [Fluorescent lamps are also ok, provided they can control the brightness].

How suitable is the following lighting conditions for your ward? [Would make all the lights in the house dimmable and controllable].

Choose the preferred window option for your ward from the list below.

Parameter 8.0

How satisfied is your ward with the following light bulb? [Fluorescent].

Parameter 9.0

How satisfied is your ward with the following light bulb? [LED].

Parameter 10

Choose the position of the light in any room that your ward prefers.

• Section C

Choose three (color numbers; for example, 71, 107, 98) from the given color matrix that makes your ward feel comfortable.

Choose three (color numbers) from the color matrix that makes your ward feel uncomfortable.

Choose three (color numbers) from the color matrix that causes your ward to become very agitated.

Choose three (color numbers) from the color matrix representing your ward’s calm and patience.

Choose three (color numbers) for the bedroom space from the color matrix above.

Choose three (color numbers) for the living room from the color matrix above.

Choose three (color numbers) for the kitchen area from the color matrix above.

Choose three (color numbers) for the dining area from the color matrix above.

Choose three (color numbers) for the washroom area from the color matrix above.

Choose three (color numbers) for the corridor area from the color matrix above.

Choose three (color numbers) from the color matrix figure given that should be avoided for your ward.

Is there a need for sensory space at home for autistic child?

Do you feel that the visual aspect is critical for autistic children?

Are any specific changes you made to make your ward feel safe and comfortable in your home?

Any ideas on what you’d like to include when designing a space for an autistic child?

This research was funded by Xuzhou Science and Technology Program under Project grant number KC21306. The authors are grateful for the funds provided by the research and development plan for the social development of the Xuzhou Science and Technology Bureau (Project number: KC21306).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

• 1. Love JS. Sensory spaces: sensory living – studio teaching the design of autism-friendly adult accommodation. Int J Arch Res Arch IJAR. (2022) 16:595–619. 10.1108/ARCH-11-2021-0321 [ DOI ] [ Google Scholar ]
• 2. Roos BA, Mobach M, Heylighen A. How does architecture contribute to reducing behaviours that challenge? A scoping review. Res Dev Disabil. (2022) 127:104229. 10.1016/j.ridd.2022.104229 [ DOI ] [ PubMed ] [ Google Scholar ]
• 3. Bottema-Beutel K, Kapp SK, Lester JN, Sasson NJ, Hand BN. Avoiding ableist language: suggestions for autism researchers. Autism Adulthood. (2021) 3:18–29. 10.1089/aut.2020.0014 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 4. Amonkar N, Su W, Bhat AN, Srinivasan SM. Effects of creative movement therapies on social communication, behavioral-affective, sensorimotor, cognitive, and functional participation skills of individuals with autism spectrum disorder: a systematic review. Front Psychiatry. (2021) 12:722874. 10.3389/fpsyt.2021.722874 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 5. Schmengler H, Cohen D, Tordjman S, Melchior M. Autism spectrum and other neurodevelopmental disorders in children of immigrants: a brief review of current evidence and implications for clinical practice. Front Psychiatry. (2021) 12:566368. 10.3389/fpsyt.2021.566368 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 6. Siller M, Morgan L, Wedderburn Q, Fuhrmeister S, Rudrabhatla A. Inclusive early childhood education for children with and without autism: progress, barriers, and future directions. Front Psychiatry. (2021) 12:754648. 10.3389/fpsyt.2021.754648 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 7. Su W, Amonkar N, Cleffi C, Srinivasan S, Bhat A. Neural effects of physical activity and movement interventions in individuals with developmental disabilities–a systematic review. Front Psychiatry. (2022) 13:794652. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 8. Van Schalkwyk GI, Volkmar FR. Autism spectrum disorders: in theory and practice. Psychoanal Study Child. (2015) 69:219–41. 10.1080/00797308.2016.11785529 [ DOI ] [ PubMed ] [ Google Scholar ]
• 9. Sukiennik R, Marchezan J, Scornavacca F. Challenges on diagnoses and assessments related to autism spectrum disorder in Brazil: a systematic review. Front Psychiatry. (2022) 12:598073. 10.3389/fneur.2021.598073 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 10. Uljarević M, Billingham W, Cooper MN, Condron P, Hardan AY. Examining effectiveness and predictors of treatment response of pivotal response treatment in autism: an umbrella review and a meta-analysis. Front Psychiatry. (2022) 12:766150. 10.3389/fpsyt.2021.766150 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 11. Baio J, Wiggins L, Christensen DL, Maenner MJ, Daniels J. Prevalence of autism spectrum disorder among children aged 8 years - autism and developmental disabilities monitoring network, 11 sites, united states, 2014. MMWR Surveillance Summaries. (2018) 67:1–23. 10.15585/mmwr.ss6706a1 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 12. Patra S, Kar SK. Autism spectrum disorder in India: a scoping review. Int Rev Psychiatry. (2021) 33:81–112. 10.1080/09540261.2020.1761136 [ DOI ] [ PubMed ] [ Google Scholar ]
• 13. Altenmüller-Lewis U. Designing schools for students in the spectrum. Design J. (2017) 20:S2215–29. 10.1080/14606925.2017.1352738 [ DOI ] [ Google Scholar ]
• 14. Fabri M, Satterfield D. Special issue on designing with and for users on the autism spectrum. Int J Hum Comput Int. (2019) 35:641–2. 10.1080/10447318.2018.1550181 [ DOI ] [ Google Scholar ]
• 15. Sahuquillo-Leal R, Navalón P, Moreno-Giménez A, Almansa B, Vento M, García-Blanco A. Attentional biases towards emotional scenes in autism spectrum condition: an eye-tracking study. Res Dev Disabil. (2022) 120:104124. 10.1016/j.ridd.2021.104124 [ DOI ] [ PubMed ] [ Google Scholar ]
• 16. Pastor-Cerezuela G, Fernández-Andrés M-I, Sanz-Cervera P, Marín-Suelves D. The impact of sensory processing on executive and cognitive functions in children with autism spectrum disorder in the school context. Res Dev Disabil. (2020) 96:103540. 10.1016/j.ridd.2019.103540 [ DOI ] [ PubMed ] [ Google Scholar ]
• 17. Roy RG, Kumar A. The mediating role of parental playfulness on parent–child relationship and competence among parents of children with ASD. Adv Autism. (2021) 8:306–18. 10.1108/AIA-02-2021-0010 [ DOI ] [ Google Scholar ]
• 18. Bitsika V, Heyne DA, Sharpley CF. The inverse association between psychological resilience and emerging school refusal among bullied autistic youth. Res Dev Disabil. (2022) 120:104121. 10.1016/j.ridd.2021.104121 [ DOI ] [ PubMed ] [ Google Scholar ]
• 19. Juliano AC, Alexander AO, DeLuca J, Genova H. Feasibility of a school-based mindfulness program for improving inhibitory skills in children with autism spectrum disorder. Res Dev Disabil. (2020) 101:103641. 10.1016/j.ridd.2020.103641 [ DOI ] [ PubMed ] [ Google Scholar ]
• 20. Maslennikova AV, Portnova GV, Martynova OV. Brain oscillatory patterns of affective prosody perception in children with autism spectrum disorder. Res Autism Spectr Disord. (2022) 96:101993. 10.1016/j.rasd.2022.101993 [ DOI ] [ Google Scholar ]
• 21. Shirama A, Stickley A, Kamio Y, Nakai A, Takahashi H. Emotional and behavioral problems in japanese preschool children with motor coordination difficulties: the role of autistic traits. Eur Child Adolesc Psychiatry. (2022) 31:979–90. 10.1007/s00787-021-01732-7 [ DOI ] [ PubMed ] [ Google Scholar ]
• 22. Black MH, McGarry S, Churchill L, D’Arcy E, Dalgleish J. Considerations of the built environment for autistic individuals: a review of the literature. Autism. (2022) 26:2753. 10.1177/13623613221102753 [ DOI ] [ PubMed ] [ Google Scholar ]
• 23. Bozkus-Genc G, Sani-Bozkurt S. How parents of children with autism spectrum disorder experience the COVID-19 pandemic: perspectives and insights on the new normal. Res Dev Disabil. (2022) 124:104200. 10.1016/j.ridd.2022.104200 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 24. Logrieco MG, Casula L, Ciuffreda GN, Novello RL, Spinelli M. Risk and protective factors of quality of life for children with autism spectrum disorder and their families during the COVID-19 lockdown. An Italian study. Res Dev Disabil. (2022) 120:104130. 10.1016/j.ridd.2021.104130 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 25. Mallory C, Keehn B. Implications of sensory processing and attentional differences associated with autism in academic settings: an integrative review. Front Psychiatry. (2021) 12:695825. 10.3389/fpsyt.2021.695825 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 26. Lane SJ, Leão MA, Spielmann V. Sleep, sensory Integration/Processing, And Autism: A Scoping review. Front Psychol. (2022) 13:877527. 10.3389/fpsyg.2022.877527 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 27. Chung JCY, Mevorach C, Woodcock KA. Establishing the transdiagnostic contextual pathways of emotional outbursts. Sci Rep. (2022) 12:11474. 10.1038/s41598-022-11474-4 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 28. Page SD, Souders MC, Kral TVE, Chao AM, Pinto-Martin J. Correlates of feeding difficulties among children with autism spectrum disorder: a systematic review. J Autism Dev Disord. (2022) 52:255–74. 10.1007/s10803-021-04947-4 [ DOI ] [ PubMed ] [ Google Scholar ]
• 29. Schulz SE, Stevenson RA. Convergent validity of behavioural and subjective sensitivity in relation to autistic traits. J Autism Dev Disord. (2022) 52:758–70. 10.1007/s10803-021-04974-1 [ DOI ] [ PubMed ] [ Google Scholar ]
• 30. Van de Cruys S, Lemmens L, Sapey-Triomphe L, Chetverikov A, Noens I, Wagemans J. Structural and contextual priors affect visual search in children with and without autism. Autism Res. (2021) 14:1484–95. 10.1002/aur.2511 [ DOI ] [ PubMed ] [ Google Scholar ]
• 31. Zhang S, Wang P, Yang B, Zhong Y, Wang Y. Characteristics of executive function in children with attention deficit/hyperactivity disorder comorbid with high functioning autism. Natl Med J China. (2020) 100:2446–51. 10.3760/cma.j.cn112137-20191216-02750 [ DOI ] [ PubMed ] [ Google Scholar ]
• 32. Clouse JR, Wood-Nartker J, Rice FA. Designing beyond the americans with disabilities act (ADA): creating an autism-friendly vocational center. HERD. (2020) 13:215–29. 10.1177/1937586719888502 [ DOI ] [ PubMed ] [ Google Scholar ]
• 33. Seidmann V. On blogs, autistic bloggers, and autistic space. Inf Commun Soc. (2021) 24:2277–92. 10.1080/1369118x.2020.1754878 [ DOI ] [ Google Scholar ]
• 34. Baumers S, Heylighen A. Capturing experience: an autistic approach to designing space. Design J. (2015) 18:327–43. 10.1080/14606925.2015.1059599 [ DOI ] [ Google Scholar ]
• 35. Fearns N, Walker L, Graham K, Gibb N, Service D. User testing of a scottish intercollegiate guideline network public guideline for the parents of children with autism. BMC Health Serv Res. (2022) 22:7384. 10.1186/s12913-021-07384-2 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 36. Ouss L, Palestra G, Saint-Georges C, Leitgel Gille M, Afshar M. Behavior and interaction imaging at 9 months of age predict autism/intellectual disability in high-risk infants with west syndrome. Trans Psychiatry. (2020) 10:743. 10.1038/s41398-020-0743-8 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 37. Fletcher-Watson S, Mcconnell F, Manola E, Mcconachie H. Interventions based on the theory of mind cognitive model for autism spectrum disorder (ASD). Cochrane Datab Syst Rev. (2014) 2014:CD008785. 10.1002/14651858.CD008785.pub2 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 38. Gaines KS, Curry Z, Shroyer J, Amor C, Lock RH. The perceived effects of visual design and features on students with autism spectrum disorder. J Archit Plann Res. (2014) 31:282–98. [ Google Scholar ]
• 39. Martin R, Wilkins J. Creating visually appropriate classroom environments for students with autism spectrum disorder. Interv Sch Clin. (2022) 57:32–7. 10.1177/10534512211014882 [ DOI ] [ Google Scholar ]
• 40. Irish JEN. Ten years on: a post-occupancy evaluation of classrooms for pupils with severe autism. Facilities. (2022) 40:656–74. 10.1108/F-10-2021-0097 [ DOI ] [ Google Scholar ]
• 41. Tarver J, Palmer M, Webb S, Scott S, Slonims V, Simonoff E, et al. Child and parent outcomes following parent interventions for child emotional and behavioral problems in autism spectrum disorders: a systematic review and meta-analysis. Autism. (2019) 23:1630–44. 10.1177/1362361319830042 [ DOI ] [ PubMed ] [ Google Scholar ]
• 42. Franklin A, Sowden P, Burley R, Notman L, Alder E. Color perception in children with autism. J Autism Dev Disord. (2008) 38:1837–47. 10.1007/s10803-008-0574-6 [ DOI ] [ PubMed ] [ Google Scholar ]
• 43. Tola G, Talu V, Congiu T, Bain P, Lindert J. Built environment design and people with autism spectrum disorder (asd): a scoping review. Int J Environ Res Public Health. (2021) 18:1–14. 10.3390/ijerph18063203 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 44. Boyce PR. Light, lighting and human health. Light Res Technol. (2022) 54:101–44. 10.1177/14771535211010267 [ DOI ] [ Google Scholar ]
• 45. Samiou AI, Doulos LT, Zerefos S. Daylighting and artificial lighting criteria that promote performance and optical comfort in preschool classrooms. Energy Build. (2022) 258:111819. 10.1016/j.enbuild.2021.111819 [ DOI ] [ Google Scholar ]
• 46. Chezan LC, Liu J, Cholewicki JM, Drasgow E, Ding R, Warman A. A psychometric evaluation of the quality of life for children with autism spectrum disorder scale. J Autism Dev Disord. (2021) 52:1536–52. 10.1007/s10803-021-05048-y [ DOI ] [ PubMed ] [ Google Scholar ]
• 47. Mayer-Benarous H, Benarous X, Vonthron F, Cohen D. Music therapy for children with autistic spectrum disorder and/or other neurodevelopmental disorders: a systematic review. Front Psychiatry. (2021) 12:643234. 10.3389/fpsyt.2021.643234 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 48. Dhiaba SAT. The impact of colour-drawing in reducing behavioural disorders for autistic children: an applied study on a sample of autistic children. Int J Innov Creativity Chang. (2020) 11:144–63. [ Google Scholar ]
• 49. Akande A. Assessing color identification in children with autism. Early Child Dev Care. (2000) 164:95–104. 10.1080/0300443001640108 [ DOI ] [ Google Scholar ]
• 50. Ludlow AK, Heaton P, Hill E, Franklin A. Color obsessions and phobias in autism spectrum disorders: the case of J.G. Neurocase. (2014) 20:296–306. 10.1080/13554794.2013.770880 [ DOI ] [ PubMed ] [ Google Scholar ]
• 51. Schloss KB, Palmer SE. An ecological framework for temporal and individual differences in color preferences. Vis Res. (2017) 141:95–108. 10.1016/j.visres.2017.01.010 [ DOI ] [ PubMed ] [ Google Scholar ]
• 52. Schloss KB, Nelson R, Parker L, Heck IA, Palmer SE. Seasonal variations in color preference. Cogn Sci. (2017) 41:1589–612. 10.1111/cogs.12429 [ DOI ] [ PubMed ] [ Google Scholar ]
• 53. Palmer CJ, Otsuka Y, Clifford CWG. A sparkle in the eye: illumination cues and lightness constancy in the perception of eye contact. Cognition. (2020) 205:104419. 10.1016/j.cognition.2020.104419 [ DOI ] [ PubMed ] [ Google Scholar ]
• 54. Koegel L, Matos-Freden R, Lang R, Koegel R. Interventions for children with autism spectrum disorders in inclusive school settings. Cogn Behav Pract. (2012) 19:401–12. 10.1016/j.cbpra.2010.11.003 [ DOI ] [ Google Scholar ]
• 55. Paulus FW, Ohmann S, Möhler E, Plener P, Popow C. Emotional dysregulation in children and adolescents with psychiatric disorders. A narrative review. Front Psychiatry. (2021) 12:628252. 10.3389/fpsyt.2021.628252 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 56. Bougeard C, Picarel-Blanchot F, Schmid R, Campbell R, Buitelaar J. Prevalence of autism spectrum disorder and co-morbidities in children and adolescents: a systematic literature review. Front Psychiatry. (2021) 12:744709. 10.3389/fpsyt.2021.744709 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 57. Thompson JIR, Peck CE, Karvelas G, Hartwell CA, Guarnaccia C. Temporal processing as a source of altered visual perception in high autistic tendency. Neuropsychologia. (2015) 69:148–53. 10.1016/j.neuropsychologia.2015.01.046 [ DOI ] [ PubMed ] [ Google Scholar ]
• 58. Shi F, Sun W, Duan H, Liu X, Hu M, Wang W, et al. Drawing reveals hallmarks of children with autism. Displays. (2021) 67:102000. 10.1016/j.displa.2021.102000 [ DOI ] [ Google Scholar ]
• 59. Faber L, van den Bos N, Houwen S, Schoemaker MM, Rosenblum S. Motor skills, visual perception, and visual-motor integration in children and youth with autism spectrum disorder. Res Autism Spectr Disord. (2022) 96:101998. 10.1016/j.rasd.2022.101998 [ DOI ] [ Google Scholar ]
• 60. Tortelli C, Pomè A, Turi M, Igliozzi R, Burr DC, Binda P. Contextual information modulates pupil size in autistic children. Front Neurosci. (2022) 16:752871. 10.3389/fnins.2022.752871 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 61. Irish JEN. Evidence-based design. Archnet IJAR. (2019) 13:25–38. 10.1108/arch-12-2018-0029 [ DOI ] [ Google Scholar ]
• 62. Gehdu BK, Gray KLH, Cook R. Impaired grouping of ambient facial images in autism. Sci Rep. (2022) 12:10630. 10.1038/s41598-022-10630-0 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 63. Schweizer C, Knorth EJ, Spreen M. Art therapy with children with autism spectrum disorders: a review of clinical case descriptions on ‘what works’. Arts Psychother. (2014) 41:577–93. 10.1016/j.aip.2014.10.009 [ DOI ] [ Google Scholar ]
• 64. Bevans KB, Piller A, Pfeiffer B. Psychometric evaluation of the participation and sensory environment questionnaire-home scale (PSEQ-H). Am J Occup Ther. (2020) 74:36509. 10.5014/ajot.2020.036509 [ DOI ] [ PubMed ] [ Google Scholar ]
• 65. Yamane T. Longitudinal psychometric evaluation of the developmental disorder parenting stressor index with Japanese parents of children with autism. Autism. (2021) 25:2034–47. 10.1177/13623613211009349 [ DOI ] [ PubMed ] [ Google Scholar ]
• 66. Pratesi CB, Garcia AB, Pratesi R, Gandolfi L, Hecht M, Nakano EY, et al. Quality of life in caregivers of children and adolescents with autistic spectrum disorder: development and validation of the questionnaire. Brain Sci. (2021) 11:7. 10.3390/brainsci11070924 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 67. Xu SQ, Zhu J, Xie Z, Li X. The psychometric properties of the Chinese version of the attitude survey inclusive education-parents. BMC Psychol. (2022) 10:808. 10.1186/s40359-022-00808-6 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 68. Wigham S, Ingham B, Le Couteur A, Wilson C, Ensum I, Parr JR. A survey of autistic adults, relatives and clinical teams in the United Kingdom: and Delphi process consensus statements on optimal autism diagnostic assessment for adults. Autism. (2022) 26:1959–72. 10.1177/13623613211073020 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 69. Tamon H, Itahashi T, Yamaguchi S, Tachibana Y, Fujino J, Igarashi M, et al. Autistic children and adolescents with frequent restricted interest and repetitive behavior showed more difficulty in social cognition during mask-wearing during the COVID-19 pandemic: a multisite survey. BMC Psychiatry. (2022) 22:249. 10.1186/s12888-022-04249-8 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 70. Moroe N, Masuku K, Shirame L. Rehabilitation healthcare professionals’ competence and confidence in differentially diagnosing deaf blindness from autism spectrum disorders: a cross-sectional survey in South Africa. BMC Med Educ. (2022) 22:3258. 10.1186/s12909-022-03258-1 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 71. Hellquist A, Tammimies K. Access, utilization, and awareness for clinical genetic testing in autism spectrum disorder in Sweden: a survey study. Autism. (2022) 26:1795–804. 10.1177/13623613211066130 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 72. Wang F, Lao U, Xing Y, Zhou P, Deng W, Wang Y, et al. Parents’ knowledge and attitude and behavior toward autism: a survey of Chinese families having children with autism spectrum disorder. Trans Pediatr. (2022) 11:1445–57. 10.21037/tp-22-113 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 73. Bhakta BB, Coleman KJ, Choi KR. Randomized study of survey recruitment strategies for parents of autistic children. J Pediatr Health Care. (2022) 36:470–3. 10.1016/j.pedhc.2022.05.008 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 74. Pulay A, Williamson A. A case study comparing the influence of LED and fluorescent lighting on early childhood student engagement in a classroom setting. Learn Environ Res. (2019) 22:13–24. 10.1007/s10984-018-9263-3 [ DOI ] [ Google Scholar ]
• 75. Pérez-Fuster P, Sevilla J, Herrera G. Enhancing daily living skills in four adults with autism spectrum disorder through an embodied digital technology-mediated intervention. Res Autism Spectr Disord. (2019) 58:54–67. 10.1016/j.rasd.2018.08.006 [ DOI ] [ Google Scholar ]
• 76. Derakhshanrad SA, Piven E. Modification of the training environment to improve functional performance using blacklight conditions: a case study of a child with autism. Int J Dev Disabil. (2020) 66:160–8. 10.1080/20473869.2019.1642640 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 77. Dirix H, Ross V, Brijs K, Vermeiren E, Timmermans C. The appraisal of roadway environment and infrastructure by drivers with autism: a qualitative study. Trans Res Part F Traffic Psychol Behav. (2021) 78:280–98. 10.1016/j.trf.2021.01.016 [ DOI ] [ Google Scholar ]
• 78. Yeoh PSQ, Lai KW, Goh SL, Hasikin K, Hum YC, Tee YK, et al. Emergence of deep learning in knee osteoarthritis diagnosis. Comput Intell Neurosci. (2021) 2021:1437. 10.1155/2021/4931437 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 79. Divan G, Bhavnani S, Leadbitter K, Ellis C, Dasgupta J, Abubakar A, et al. Annual research review: achieving universal health coverage for young children with autism spectrum disorder in low-and middle-income countries: a review of reviews. J Child Psychol Psychiatry. (2021) 62:514–35. 10.1111/jcpp.13404 [ DOI ] [ PubMed ] [ Google Scholar ]
• 80. Green J, Garg S. Annual research review: the state of autism intervention science: progress, target psychological and biological mechanisms and future prospects. J Child Psychol Psychiatry. (2018) 59:424–43. 10.1111/jcpp.12892 [ DOI ] [ PubMed ] [ Google Scholar ]
• 81. Teo K, Yong CW, Muhamad F, Mohafez H, Hasikin K, Xia K, et al. The promise for reducing healthcare cost with predictive model: an analysis with quantized evaluation metric on readmission. J Healthc Eng. (2021) 2021:138. 10.1155/2021/9208138 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] [ Retracted ]
• 82. Sengupta K, Shah H, Ghosh S, Sanghvi D, Mahadik S, Dani A, et al. World health organisation-caregiver skills training (WHO-CST) program: feasibility of delivery by non-specialist providers in real-world urban settings in India. J Autism Dev Disord. (2021) 51:1–8. 10.1007/s10803-021-05367-0 [ DOI ] [ PubMed ] [ Google Scholar ]
• 83. Dhanalakshmi S, Venkatesh C. Classification of ultrasound carotid artery images using texture features. Int Rev Comput Softw. (2013) 8:933–40. [ Google Scholar ]
• 84. Green J, Leadbitter K, Ainsworth J, Bucci S. An integrated early care pathway for autism. Lancet Child Adolesc Health. (2022) 6:335–44. 10.1016/S2352-464200037-2 [ DOI ] [ PubMed ] [ Google Scholar ]
• 85. Salah BM, Sakher S, Darawsheh SR, Quraann EA, Zaghlool ZDM, Alkhawaldeh MA, et al. Guidance for autistic children in increasing confidence in socializing. Inf Sci Lett. (2023) 12:807–12. 10.18576/isl/120222 [ DOI ] [ Google Scholar ]
• 86. Nagib W, Williams A. Creating “therapeutic landscapes” at home: the experiences of families of children with autism. Health Place. (2018) 52:46–54. 10.1016/j.healthplace.2018.05.001 [ DOI ] [ PubMed ] [ Google Scholar ]
• 87. Mcallister K, Hadjri K. Inclusion and the special educational needs (SEN) resource base in mainstream schools: physical factors to maximise effectiveness. Supp Learn. (2013) 28:57–65. 10.1111/1467-9604.12019 [ DOI ] [ Google Scholar ]
• 88. Willis KS, Cross E. Investigating the potential of EDA data from biometric wearables to inform inclusive design of the built environment. Emot Space Soc. (2022) 45:100906. 10.1016/j.emospa.2022.100906 [ DOI ] [ Google Scholar ]
• 89. Caniato M, Zaniboni L, Marzi A, Gasparella A. Evaluation of the main sensitivity drivers in relation to indoor comfort for individuals with autism spectrum disorder. Part 1: investigation methodology and general results. Energy Rep. (2022) 8:1907–20. 10.1016/j.egyr.2022.01.009 [ DOI ] [ Google Scholar ]
• 90. Caniato M, Zaniboni L, Marzi A, Gasparella A. Evaluation of the main sensitivity drivers in relation to indoor comfort for individuals with autism spectrum disorder. Part 2: influence of age, co-morbidities, gender and type of respondent on the stress caused by specific environmental stimuli. Energy Rep. (2022) 8:2989–3001. 10.1016/j.egyr.2022.01.011 [ DOI ] [ Google Scholar ]
• 91. Lord C, Risi S, Lambrecht L, Cook EH, Leventhal BL. The autism diagnostic observation schedule-generic: a standard measure of social and communication deficits associated with the spectrum of autism. J Autism Dev Disord. (2000) 30:205–23. 10.1023/A:1005592401947 [ DOI ] [ PubMed ] [ Google Scholar ]
• 92. Baron-Cohen S, Wheelwright S, Skinner R, Martin J, Clubley E. The autism-spectrum quotient (AQ): evidence from asperger syndrome/high-functioning autism, males and females, scientists and mathematicians. J Autism Dev Disord. (2001) 31:5–17. 10.1023/A:1005653411471 [ DOI ] [ PubMed ] [ Google Scholar ]
• 93. Ma S, Li M, Qiao Y, He H, Luo M. The effective learning of discrete trial teaching: evidence from pre-service teachers of children with autism. Acta Psych Sin . (2023) 55:237–256. 10.3724/SP.J.1041.2023.00237 [ DOI ] [ Google Scholar ]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

• View on publisher site
• PDF (6.8 MB)
• Collections

Similar articles

Cited by other articles, links to ncbi databases.

• Download .nbib .nbib
• Format: AMA APA MLA NLM

Add to Collections

Scandinavian Journal of Disability Research

• Download PDF (US English) XML (US English)
• Alt. Display

Structured flexibility: six case studies of how children with diagnosed autism develop independency in daily living activities

• Mona E. Holmqvist
• variation theory
• experiences of the environment

Introduction

According to Vygotskij ( 1997 ), learning is a development of ability to interact with other participants in the environment. In this study, learning is generally defined as the ability to experience the world in a new way, or in new ways, different from those previously held by the learner (Marton and Booth 1997 ) – and by this, to understand how to act in the natural environment.

It is frequently claimed that children with autism benefit from special education (Jordan and Powell 1995 ; Schopler and Mesibov 1995 ; Quill 1995 ). However, it is hard to find what theoretical assumptions about learning the studies are based on. Instead, learning often seems to be identified as memorizing how to behave in restricted situations. In this article, learning is, as already mentioned, defined as new ways of experiencing the environment and more powerful acting in the environment. This point of departure differs from the focus in studies on learning and autism where instructional strategies are in focus. In such studies, the result is strongly connected to the observable behaviour in a restricted environment, instead of learning outcome concerning the content which cannot easily be quantified and measured. Education is thus seen as a form of behaviour treatment, instead of a development of the participant's deep understanding of the environment and how to act in new situations. By this, the unwanted behaviour is measured and if it has decreased it is claimed the participant has learnt. It is seldom questioned what has been learned. The behaviour could have decreased because of the participant's deep understanding of why s/he should not continue doing it, or the participant could have understood the instructor's reinforcers but not why s/he should change behaviour – which results in two quite different learning outcomes, even if the observable outcome is the same.

Lord and McGee ( 2001 , 90) say, ‘there is a small literature on instructional strategies designed to promote the academic performance of young children with autism’. The focus in the present study is not on academic performance. However, the focus on the children's deep understanding, instead of learning how to handle a couple of behaviours which for some reason have to be modified, is shared in the present study and in Lord and McGee's study. Learning situations for children with autism are often strongly focused on one single detail and carried out with strict structure and routine (Howlin 1998 ), based on the fact that flexibility is hard to achieve for individuals with autism. There is, however, no need to restrict the learning situation because of the participants’ impairments, as it can end up in school situations where the only way it works is when the child does the same thing at the same place month after month. The theoretical assumption of learning used in this study would not define such activity as learning. As a consequence, this study has a holistic point of view; the child has to consider more than one variable at the same time (in a real situation) instead of single variables (in a restricted environment). If theoretical points of departure about learning were distinctly clarified in studies about autism, the understanding of how and what people with autism learn would be easier to grasp. Lord and McGee ( 2001 , 92) say:

There is need for research on the development of more specific measures of important areas of outcome in cognition, including the acquisition and generalization of problem-solving and other cognitive skills in natural contexts (e.g., the classroom and the home) and the effects of these skills on families and other aspects of children's lives. There is also a need for research to define appropriate sequences of skills that should be taught through educational programs for young children with autistic spectrum disorders, as well as methods for selecting those sequences, while developing programs for individual children.

As autism is a rather new research phenomenon, the initial research focus has been how to cure the disease instead of how to help the individuals handle the symptoms of the disability. When autism was first described (Kanner 1943 ), research was overshadowed by the search for different cures (Baron-Cohen 1995 ; Holmqvist 1995a , 1996 ). Instead of developing scientific theories about learning applied to individuals with autism, there has been a strong emphasis on behaviour modification programmes (e.g., Lovaas and Buch 1997 ). But applied behaviour analysis and functional behavioural assessment approaches focus on the observable behaviour, instead of the ability to deeply understand a new concept (Austin and Carr 2000 ). The question of how to teach has been more developed than the question of what it takes to learn (Lord and McGee 2001 ). To distinguish between behaviour modification and learning, there is a need to explain the scientific theoretical assumptions about learning on which the studies rely – if the results claim learning has occurred. Otherwise it is hard to discuss if and what the participants really have learned.

It is well established that children with autism have multiple problems involving joint attention and perspective-taking (Cohen 1998 ; Frith 1989 ; Gillberg 1995 ; Wing 1996 ). They display a number of deficits in the ability to jointly attend to objects with other people; they produce very few declarative gestures and they engage very little in symbolic or pretend play (Happé 1994 ). Some high-functioning children with autism have the ability to adopt the role of another, but lower-functioning children with autism are very poor at accommodating another person's perceptual perspective (Duvner 1994 ). One among many conclusions is that children with autism as a group have difficulties in taking another person's point of view, and sometimes they are characterized as being basically ‘acultural’ (Grandin 1986 ; Schopler and Mesibov 1995 ). One theory about the source of problems of children with autism is that they have difficulty in identifying with other people (Tomasello 1999 ). If they have deficits in understanding another person's intentional actions, it is hard for them to predict the behaviour of others, as well as to discern what other people expect of them. The question, ‘Can you turn off the light, please?’ answered by a ‘Yes’, but with no follow-through, is an example of such an environmental problem. When you are observing a child with autism, this complicates how to interpret and measure the observable behaviour, as you in fact do not know what it stands for. By the use of a theoretical framework it is possible to predict the intention of the observed behaviour, and based on such predictions arrange instruction. If the theoretical framework really works and seems to be powerful, the child should develop in the predicted way. Even if there are several studies describing how to increase ability or decrease unacceptable behaviours, it is hard to find studies with this point of departure. In most studies the behaviour seems to be in focus, and the work seems to be empirical based. The question of why some methods seem to benefit some children, as other methods seem to benefit other children, might be possible to answer if we can find a theoretical way to explain why the methods are or are not powerful in a defined situation. By doing this, it would also be easier to predict what kind of method or instruction is needed in new situations.

Unlike other children who have a common understanding of people as intentional agents, children with autism have a cognitive difficulty that emanates both from identification with other people and from the intentional organization of their own sensory-motor actions. This development emerges very early in normal infancy and is unique to the species, emerging around eight or nine months of age (Tomasello 1999 ). This exposes the normally developing child to the uniquely human forms of cultural inheritance, an area in which we cannot expect children with autism to participate without educational training. Other theories about the origin of cognitive disabilities related to autism are weak central coherence (Happé, Briskman, and Frith 2001 ), executive disorder (Russell 1997 ) and an extremely atomistic experience of the environment (Holmqvist 1995a, 1995b).

The extremely atomistic experience results, for example, in a deficient ability with joint attention. It is not an area of study in ‘normal’ children's education, because it is seen as a natural development. Although we can investigate the development of attaining joint attention, we are not yet accustomed to educate in areas which could be classified as ‘learning to be a human being’. How can you discern aspects of a phenomenon if it is so integrated into your mind that you cannot even recognize it? The best we can do to help seems to be to build theories of learning which can be tested in natural settings. This study is one contribution in the direction of theorizing that learning is a broad environmental experience, focusing on both social action and cognitive skills, or in this case, learning to see the critical aspects that define what it means to act as a human being in our society.

Theoretical framework – the variation theory

Variation theory is one among many possibilities for increasing teachers’ qualifications to help students with autism improve their ability to enter into society (Holmqvist 2004a, 2004b). It focuses on intentional learning, learning which is aimed to develop another person in a specified direction (Marton and Booth 1997 ; Marton and Fai 1999 ; Marton and Trigwell 2000 ; Marton and Tsui 2004 ; Holmqvist 2004b ; Holmqvist, Gustavsson, and Wernberg 2008 ; Runesson 1999 ). Variation theory focuses on what an individual can possibly discern in the environment, what they can discern simultaneously and the kind of variation they can deal with to develop a deep understanding of the targeted learning object (Marton and Booth 1997 ). Based on the theoretical framework, three dimensions are analysed in a learning situation; the distinction between; (1) an intended object of learning (which is what the teacher has planned); (2) an enacted object of learning (what actually takes place in the learning situation, possible to observe by a researcher); and (3) the lived object of learning (the student's learning outcome) (Marton 2000 ). Instead of trying to find the right teaching methods, variation theory is a tool to use in examining different learning objects to find how learning develops in different ways connected to the learning object and the learner. For learning to take place, a way of understanding an object can be defined in terms of critical features that must be discerned and focused on simultaneously. An individual must experience some kind of variation in order to discern a particular feature. To develop a certain way of seeing something, a teacher needs to construct the pattern of variation that is necessary for students to experience it.

Variation theory is built on research about discernment (Rubin 1915 ; Wertheimer 1959 ; Gibson 1986 ), simultaneity and variation (Bransford and Schwartz 1999 ; Schwartz and Bransford 1998 ). In all phenomena, in every situation, certain aspects are discernable. If every aspect could be discerned and focused on at the same time by everyone, everything would be experienced in exactly the same way. However, only a limited number of aspects can be discerned and focused on at the same time.

To experience means to be able to discern something from a given context and relate it to this context or another. It also means discerning parts of what we experience and relating the parts to each other and to the whole (Carlgren and Marton 2002 ; Wertheimer 1959). To discern the geometrical shape in Figure 1 you have to discern the three black symbols as a whole to see the triangle. In order for us to discern something, we must focus on some aspects whereas others remain unfocused. To make it possible to focus on some aspects, they need to be varied against an invariant background, i.e., variation is necessary for discerning and discerning is necessary for experiencing. The contrasts between what varies and what does not, result in a pattern of contrasts which make it possible for us to discern. The contrasted aspects that are possible to focus on simultaneously make a new way of experiencing, which changes as different aspects change. If you describe a girl as short for her age, you have contrasted in your mind examples of other girls of the same age but of different heights. Otherwise you probably would not mention anything about her height.

Geometrical shape, triangle, without edges.

One of the difficulties in teaching students in areas familiar to the teacher includes the lack of awareness as to how the students’ understanding of the object of learning can differ from the teachers’. So, how do we know what dimensions of variation to look for? How do we identify the critical features? According to Marton and Tsui ( 2004 ), the critical features have to be found empirically and they must be found for every specific object of learning.

The teacher must enable students to focus on critical aspects of the object of learning. Some aspects must be presented as basic and others focused on through variation. The basis is the knowledge shared by teacher and students. To create a learning space means to open up a dimension of variation that offers students new ways of discerning critical aspects (Marton and Tsui 2004 ). The dimensions include aspects of phenomena, but parts of the phenomena can be separated in new dimensions as a kind of differentiation or enrichment, when the learner gains a deeper understanding. But the question is: what kind of variation provides the students with the best opportunities to learn? Schwartz and Bransford ( 1998 , 507) found:

In domains in which students have less prior experience, less complex contrasting cases may be more appropriate lest students get lost in the little contrasts […] The contrasts between the tools are less ‘cluttered’ compared to the contrasting cases of these studies. This makes it so students with limited algebra knowledge can still locate the important contrasts.

Variation theory offers an opportunity to conduct microanalyses of the enacted object of learning (what actually happens in the lesson). The results of these microanalyses can be used to change very subtle details in the educational situation, which can result in totally different student learning outcomes. They also highlight the difficulties the pupils have in a learning situation, difficulties which may have been unnoticed without the microanalyses and hard to catch if they strongly differ from the teacher's ways of understanding.

The aim of this study is to describe in what ways variation can be used in learning situations for pupils with autism to evoke deep understanding of daily activities in natural settings.

In this study, already-existing teaching methods are used to instruct children with autism, such as the TEACCH-method (Schopler and Mesibov 1995 ), social stories (Reynhout and Carter 2006 ), activity schedules (McClannahan and Krantz 1999 ) and how children read social situations and emotions (Howlin, Baron-Cohen, and Hadwin 1999 ; Gray 1995 ). However, the aim of this study is to describe in what ways variation can be used in learning situations for pupils with autism to evoke deep understanding of daily activities in natural settings, and not to study the effects of the teaching methods used. The methods for data collection are videotaped observations of the child's ability before and after the research lessons/activities and videotaped observations of the lessons/activities. To analyse the students’ baseline ability, the variation theory is used, which means the focus is on three concepts; discernment, simultaneity and variation. Every participant was observed initially to describe what s/he already has discerned about the learning object, what could be discerned simultaneously and what kind of variation the participant seemed able to handle.

In six case studies participants with different abilities and different learning objects are described in a kind of technical action research project (McNiff and Whitehead 2005 ; Tomal 2003 ). The methods used are video observations and design experiments (Brown 1992 ; Kelly et al. 2000 ) in natural environments with factors that cannot be controlled as well as factors that can. The initial observations of the participants show which aspects of the learning object the child focuses on and which are unfocused, what the participants seem to discern, what they discern simultaneously and the kind of variation they can handle. The research team plan educational settings, based upon the initial analysis, which aim to help the participant discern new aspects or to focus on several aspects simultaneously. After the learning session/sessions, the ability to use the developed abilities is observed in natural environments. The video recordings are made twice initially (before the teaching situations), during the learning sessions (3–5) and as a single follow-up two to three months later. Each case is carried out within six months.

Participants

Six children participated in this research project. They were selected by a group of students who had attended a university course on autism. All of the students were also working with individuals with autism as professionals during the course period. First of all, the respondents were selected by their differences in age (7–15 years), developmental age, sex and language (four with different verbal abilities and two not verbal). Secondly, they should also have some kind of pervasive difficulties which made them impaired in their daily activities, regarding both their parents and professionals. Third, all of them have autism or Asperger's syndrome as a diagnosis through medical examinations carried out by specialized teams at hospitals, based on Wing's triad or DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders) (American Psychiatric Association 1994 ). All of them were placed in classes for children with special educational needs, and four of them also had cognitive disabilities. The reason for this kind of selection was to see if and how variation could be used in learning situations where different kinds of individuals with autism or Asperger's syndrome participate (see Table 1 ).

Table 1. Participants and learning objects in the six case studies.

The case studies have been carried out in this sequence:

• 1.   Choosing learning object . The learning objects were defined in discussions between the respondents’ parents, teacher and one member of the research team. In most cases, the member of the research team is also the respondent's teacher or student assistant.
• 2.   Initial knowledge. Analysis based both on the participants’ behaviours, documented by video recording, and the variation theory focusing on what s/he has discerned (A), if s/he can discern more than one aspect at a time (B) and what kind of variation s/he can handle (C). Two video observations per child were made during the same week, one at home and one at school. The analysis was made by a group of 19 researchers and special needs teachers attending a university course about autism. All of them have worked for several years among individuals with autism. The team was divided into six smaller groups, with the focus on one child each. After each video observation, the team met and analysed the videos together, to reach a high inter-reliability.
• 3.   Defining the chosen learning object . After analysing the video sequences, more exact suggestions were made about what aspects should be focused on at the instruction. Each case group contacted parents and staff to define an ability that needed to be further developed by the respondent.
• 4.   Critical aspects in a dimension of variation of the learning object are analysed by answering the question: ‘What does it take to master the ability analysed?’ This means to consider, by reading previous research, what is already known as being difficult to learn for a child with this kind of impairment. If the learning object was eating food, we had to understand what kind of obstructions the child struggles with; otherwise we can hardly make a successful learning situation.
• 5.   Video observations of target situations . The respondents are observed in situations where the ability is needed. Every team group video recorded the child in the targeted situations, to see how s/he handles the critical aspects.
• 6.   Analysis , in the whole team group, of the aspects the participant responded to, and those which were not responded to. By studying the participant in a natural situation, attempts are made to capture the aspects s/he has already experienced and those s/he has not. Since it is impossible to talk with four of the participants about their understanding, observations became very important.
• 7.   Creating the learning situation . Based on the observations, a teaching situation is planned in the entire research group, but carried out in the smaller case groups (one per respondent). The teaching situation aims to enable the participant to experience more or other aspects of the learning object, such as part/whole connections or to generalize to other situations. Video-observed teaching activities (three–five lessons per participant) took place over one month or until the targeted ability was reached.
• 8.   Assessment of increased quality of the ability the study is focusing on. During and after each teaching situation, focused video observations are carried out to verify if the ability has improved or if more instruction is needed. If the latter is true, the process starts again at step five. A comparison of the different observations was analysed to determine in which way and how changes have occurred. This is based upon the children's responses to the aspects made discernable by the instruction, such as showing how to pick items in a shop or how to use a schedule.
• 9.   A follow-up study was made to see if the ability remains or changes over time. Two months after the ability was stated as learned, video observations were made in the small groups, and analysed by all the team members together.

The first case study is about a seven-year-old boy who has difficulties in understanding a meal situation. Charles is verbal, but he uses language in his own way, very little of which includes using words in a conversation. It is also difficult to understand how much he understands what he is told. He appeared to be unaware of the meaning of food during the meal and the rules for how to join in social activities at the table. He ate if someone gave him food on his plate, but he was unable to ask for food if it was not served. On the other hand, he often asked for food when he was not sitting at the dinner table.

The first analysis resulted in an assumption that he did not ask because he did not see where the food that was put on his plate came from. If he did not experience the food aspect when it was served in deep opaque dishes, and was not able to make the connection as to how others got food on their plates by serving themselves, it is obvious he could not act differently. However, when the food was served in deep transparent glass dishes, he showed exactly the same lack of ability. Seeing the food aspect was not the problem.

The second analysis resulted instead in an assumption that he was used to being served, and so he just waited until someone served him. A meal situation was constructed in which he was not served any food while the others at the table had their dinner. He did not make any attempt to ask for food or serve himself during the meal. A while after the meal was completed, and the other people left the table, he was served, otherwise he would not have had anything to eat. Although he was able to see the food and to serve himself, there was no change in his way of participating.

In the third analysis the focus was on the patterns of variation possible for Charles to experience during a meal situation. There were four to seven people sitting at the table. During the meal, they conversed and the sound of cutlery against china could be heard. Along with all the movements the people made while serving themselves, it seemed as if there were too many varied aspects. We had assumed that Charles had better previous knowledge than he in fact had. This was shown by how he acted when the ‘cues’ he needed to act were removed. We found that he turned off his attention during the meal. So, not seeing the food and not serving himself turned out not to be the critical aspects. We had observed this in other situations. It was, in fact, the number of varied aspects that made him unable to focus on the aspects which were critical to developing knowledge about how to act at meals. The balance was not maintained between the learner's previous knowledge and the complexity offered in the contrasted aspects as shown in Figure 2 .

The learning diagonal. The relationship between the learner's ability to learn by discerning the critical aspects offered in the learning situation in relation to their previous knowledge.

In the third analysis we examined which aspects could vary and which were kept invariant. To focus on the food dimension (represented by many different aspects, such as potatoes, vegetables, etc.) we chose to let Charles eat alone initially. In so doing, we maintained invariance in the situation at the table. The aspects of food did vary in order to make him understand how to choose and ask for different things. The food was represented in pictures, which were kept near Charles's plate. To get a desired food he had to ask by words or signs (pointing at a picture). He also had to discern the quantity aspect, since he had to serve himself from the deep dishes. The teacher asked him how much he wanted, if it was too much or too little, while he served himself. In this way, he could understand the meaning of the expressions ‘too much’ and ‘too little’ and connect them to how much he could eat; at the same time he was to learn how to get food on his plate. In this situation, he was able to understand which aspects were critical to focus on in a meal situation and which were not. Other people's conversation and movements should be unfocused, which was demonstrated to him by reducing them initially. Charles was placed in a situation where he only had to discern the critical aspects concerning food. This was necessary as he otherwise focused on aspects not critical for understanding a meal situation. When he had developed knowledge about the learning object, this ability was transferred to a situation including more people also eating sitting around the table. By analysing Charles's activities, we found that he was able to understand and act appropriately in a meal situation, with the pictures as support. In this way, variation was decreased in the beginning to make him focus on the critical aspects, and then increased in terms of letting more people join the meal situation without losing the focus on the critical aspects in it (see Table 2 ). The results show how Charles improved his ability to act more appropriately in a meal situation. He now asks for different items, and he focuses on eating when sitting at the table.

Table 2. The relation between varied and constant aspects in a dimension of variation.

The second case study involved a 10-year-old girl with difficulties in understanding her work schedule. Liza can speak a few words. Her independent work activity was observed, and critical aspects were identified. Her schedule consisted of pieces of paper on which there were circles in different colours. They were fastened to a board with four paper clips and were attached to the board in the same order every day, as shown in Figure 3 .

Schedule board.

The teacher said this was because Liza became confused if the order was changed. Four plastic boxes were placed on a shelf beside her workstation. They had the same symbols as the pieces of paper on the schedule and were placed in exactly the same order every time.

To learn the concept of the schedule, the situation was studied from theoretical assumptions about discernment, simultaneity and variation. We found that Liza had not been offered the opportunity to discern the function of the schedule. It was removed and a second observation of how she handled her work without the schedule was carried out. It showed that she managed to perform the tasks anyway, by taking the boxes from the shelf in the order from left to right.

The aim of this activity was for her to develop an understanding of a schedule, which could be used in new situations. Liza had learned to find the work material in the different boxes, but not the intended object of learning, i.e., to use a schedule. To provide her with possibilities to do so, she had to focus on the critical aspects of the object of learning. One critical aspect was to follow the schedule, in one direction, no matter what colour the shapes were. The invariant aspect was to read the symbols from left to right every time, and the varied was where the symbols were placed on the board. The second critical aspect was the connection between the symbols on the schedule and the symbols on the boxes. To get Liza to focus on this connection, variation was built in by changing the order of the boxes, avoiding duplication of the order on the schedule. In this case, the invariant aspect was to match the symbols on the schedule with the symbols on the boxes and the varied was the order in which to pick the boxes from the shelf. Learning how to use a work schedule includes discerning the connection between the schedule and workboxes simultaneously. This became possible by building a necessary amount of variation in the educational situation. Liza has since developed the ability to use the schedule which includes accepting changes indicated by it (see Table 3 ).

Table 3. The relation between varied and constant aspects in a dimension of variation.

Max is an 11-year-old boy. He does not speak but he uses sound to communicate how he feels. His problem is to join in a meal situation, as was the problem for Charles, but Max's situation is the opposite of Charles's. Charles did not serve himself, but Max did not know which food he was allowed to eat and which he had to share with others. He was totally focused on food the whole day and would run to the kitchen as soon as he could to get more. When he did not succeed, he became angry with the staff and would bite and hit if they did not give him food.

The first analysis resulted in identifying two critical aspects: food as a thing to share with others and the distinction between food on his plate and that in the serving dishes. Max saw all food as his, and he could eat from any plate or dish he found. He did not seem to understand that others at the table should share the food served. He also ate any food he saw, as if he could not see food without eating it. He was very worried when he saw the symbol for food on the schedule, and he was focused on it instead of the present activity. If food was represented as the third symbol, he did not read the schedule from top to bottom; instead he focused on the symbol for food without noticing the order of the activities in the schedule. This was another critical aspect – the understanding of a schedule – also present in the case study of Liza.

The two learning objects (to read a schedule and to reduce the obsession with food) had to be dealt with in two different ways. To get him to focus on the order of the schedule instead of the activities in it, he was offered a schedule with decreased variation. By using a schedule which only showed activities in a sequence where the first always is a meal (constant) and the other activities are not connected to food, he did not have to wait for the meal situation in the same way. The varied aspect in the schedule was the order and content of the other activities, while the meal sign was kept invariant or constantly first in the sequence. Secondly, to provide him with a new experience of food, he was offered increased variation of the food dimension. This was a variation in which different shapes of food were introduced and in activities where he had to work with food without eating it. He could also watch TV programmes about cooking, an activity he liked very much. After a few weeks, a change in his behaviour at meals was observed. He did not run to the kitchen any more; he did not eat everything he saw and he really seemed to enjoy cooking for both himself and others. The way variation was used ( Table 4 ) to change his experience of the environment has been very effective in making him understand the critical aspects needed to participate in activities concerning food. In addition, he is much calmer in other situations, as his food obsession has decreased and he now allows himself to concentrate on other activities. Max has developed an ability to handle food without eating it in situations where it is not supposed to be eaten, and to act in an acceptable way at the table.

Table 4. The relation between varied and constant aspects in a dimension of variation.

The fourth case study is about a 12-year-old girl who finds it difficult to shop. Jessica does not use verbal language. By observing her, information was gathered about which dimensions of learning she seemed able to experience. The teacher assumed it would be too difficult to buy more than one thing at a time. She went to the shop with a teaching assistant to buy rolls for the afternoon break at school. She showed a great amount of anxiety in the shop, and it was hard for her to find the rolls as well as to understand how to queue up. Instead of understanding the meaning of shopping, she was totally focused on getting the rolls. She was not able to focus on more than one item at a time. A situation was designed where she had to focus on the whole shop simultaneously with the function of queuing to pay. To give her opportunities to focus on the varied range of items, variation was offered in the educational situation, represented by pictures of items in the shop other than the rolls. After looking at the pictures, the teaching assistant and Jessica went to the shop to find the items in the natural setting. The connection between shopping and just visiting the shop was shown in the distinction of paying or not paying.

The teaching assistant wrote an instructional story, describing the critical aspects of going shopping, based on a theoretical analysis of the girl's observed experience. She also made a portable schedule, with pictures of different articles in the shop, and pictures of the different steps required for queuing to pay for the articles. After three shopping trips, Jessica showed no anxiety at all, rather excitement. In the last videotape from her shopping, she even turned to the teaching assistant with a smile, pointing at a box of soft cheese (which had not been introduced as an article for her) with a face expression saying: ‘Could we buy this too?’. Shopping has become more to her than just picking up rolls for the afternoon break. She continued her shopping skills with her family. Instead of having experienced shopping as a chaotic activity for all involved, she now helps her mum choose articles instead of having outbursts because she does not have a clear and understandable picture of the activity. Shopping includes doing different things every time, which in turn blocks every attempt to create an ‘everyday theory’. This frustrated her when she went to the shop because she did not experience the invariant aspects of the concept.

In this case she now is able to make connections at a more developed level, which helps her to deal with the variation she has to consider simultaneously with queuing in the shop. Jessica was given the opportunity to become aware of the connection between choosing items and paying for them as a sort of exchange. The other difficulty, queuing up to pay, showed she had not realized how to move when the queue moved forward. Finally, she was not able to see the connection between when to place her own items on the conveyor belt in relation to the other customer's items. For Jessica to gain these insights, i.e., to focus on the needed critical aspects, the teaching assistant initially enabled her to focus on the ‘next customer’ stick. Jessica was shown to put her items on the conveyor belt after this divider. The problem was that she did not wait to put the ‘next customer’ stick on the conveyor belt until the previous customer had placed all of her items on the conveyor belt, which resulted in a mix-up of items. In the next learning session, the teacher instead had her focus on the belt having to be empty before Jessica could put her items on it. This was presented to Jessica by photos of an empty conveyor belt the next time they visited the shop. In this study, the shop was kept invariant, while the things that varied were the items to buy. Further development includes a variation of shops, as described in situations 4 and 5 in Table 5 . Jessica has improved her ability to go shopping in how to choose items, how to queue before paying and how to act when she is supposed to pay for her items.

Table 5. The relation between varied and constant aspects in a dimension of variation.

Mary is 13 years-old. She is verbal and on a higher level than the four previous presented participants. Because of this, her disabilities are not as explicit. However, the learning object is in an area not often talked about in public. Mary's difficulty in understanding her menstruation cycle is grounded in her strong connection between blood and death. She thought she was very badly hurt when she saw blood in her bed one morning. In the interviews with Mary, critical aspects concerning what blood is and when blood is dangerous, along with the biological differences between men and women, had to be discussed. First, the teacher showed Mary a picture of a woman (similar to a paper doll) where the blood circulation was depicted ( Table 6 ). Then, she showed the same doll with the menstruation cycle depicted. By that she was able to discern the difference between losing blood from the two systems, one as dangerous and the other as normal. After that, she gave Mary the opportunity to see how she could predict when she would have her period. This was done from two perspectives: according to the cycles of the months and according to the life cycle. From the second perspective she was also informed that young girls and women over 50 usually do not menstruate, which is related to becoming pregnant. From this perspective she also realized that the reason men were not able to have babies was because they do not menstruate. Finally, she was informed how to take care of her feminine hygiene. The critical aspects found in this learning object were the differences between toilet facilities. Those for women usually have a waste box for sanitary towels, which is not the case in toilets for both women and men. Because of that, she had to be instructed in two different ways to take care of this. The teacher considered the variation needed to create new learning about the two different learning objects, and the outcome showed that Mary was able to take care of her situation independently and her anxiety disappeared. She had developed an understanding of how to handle her period and the related hygiene.

Table 6. The relation between varied and constant aspects in a dimension of variation.

Paul is in puberty and is rather high functioning. He is 15 years-old and his problem is connected to physical movements. He still moves as though he was a little boy, even though he is a tall young man. His movements include jumping, ritualistic walking patterns and other repetitive movements. Since he is so tall, he risks hurting himself by hitting the ceiling when he jumps indoors. People who do not know him find this behaviour very odd and it results in more repudiation than needed. Paul is able to understand written instructions and social stories have been used to help him shop independently. However, his physical movements appear as if he has no control over them. But since he seems to enjoy these activities, the aim is not to forbid them entirely; it is instead to give him the chance to learn other, more age-appropriate ways of moving, and the situations when his own ways of moving are allowed. The critical aspects identified are Paul's very limited ways of moving his body and his limited understanding of what are typical movements for his age and in different settings. To get him to focus on these aspects, the teacher offered him an increased variation concerning physical activities and a decreased variation concerning where the different physical activities were allowed to take place. These two aspects needed to be focused on simultaneously. First of all, the teacher introduced different ways of walking instead of letting him walk back and forth in the same spot as usual. Then she showed him examples of how other boys his age move, compared to how younger boys move. He was told that every person has his own private area, where he can do things that are not appropriate in other places. If he was not supposed to jump inside at school and in public where other people could see him, he was still allowed to jump in his room, as long as he did not hurt himself ( Table 7 ). Although this has been a problem for Paul for four years, he now moves more like other teenagers. His parents have reported that they see him now and again coming from his room, warm and red in his face from jumping. But no comments are made and he feels secure in his privacy. Obviously, this activity is something that gives him pleasure and forbidding it would not be fair. If variation had not been used in this learning situation, the teacher would have probably forbidden all jumping to reduce such behaviour. In this case, Paul has been given the opportunity to learn the connection between his acts and those of other people. By doing so, he developed an understanding of the differences between doing things when people are present and when they are not, a difference he was not aware of initially.

Table 7. The relation between varied and constant aspects in a dimension of variation.

Teaching children and young people with autism has often been characterized by training rather than focusing on learning as a development in experiencing the environment. The training is often built on routines, carried out over and over again, and reinforcers are used, aiming to correct the person's behaviour. If learning is seen as a new way to experience, and by that to act in the environment, such school situations cannot be seen as learning activities. The results in this study show how variation, in a planned and structured way, makes the respondents in the six case studies more aware of what is expected of them in a situation. By making them discern connections between isolated events, their ability to act appropriately seems to develop. The disability has been described in terms of weak central coherence, lack of executive functions or theory of mind, etc. Findings show agreement in the literature that special needs education is the best way to help these individuals. Despite this, in most of the studies it is unclear how learning and special education are defined in a theoretical perspective. Because of this, educational practices seem to lack theory, at least in terms of theories on learning. In this study, we have examined how to use a theory to develop more insight into knowing what it takes to learn. Educational situations were designed in a way that made the pupil focus on the critical aspects of learning, and to make connections between different aspects, thus creating a better way of understanding the object of learning. The studies have demonstrated the advantage of making the student focus on the connections between different aspects rather than single aspects, one at a time. To make this happen, the balance between variation/invariance has to be considered. Instead of creating methods for teaching children with autism, the focus has been on the relation between how an individual experiences the world and which critical aspects have to vary to make it possible for the individual to discern new aspects. The variation presented in the case studies is very distinct in identifying the critical aspects in a learning situation. Even if the same method is used, a change in those aspects which vary and those which do not vary makes the difference. Variation theory is powerful both in the analysis and the planning of learning activities. The results of the case studies also show possible connections among different assumptions of the features of autism. This has to be further developed, but it is worth considering the fact that these individuals show an extremely atomistic way of organizing experiences in the environment, which results in a weakness in central coherence and executive functions. As a result, it is hard for them to develop a theory of mind or inter-subjectivity. This might be the reason that special education seems to be the most powerful way to assist children with autism in their development. If the main characteristic of autism is a way to experience the world as extremely atomistic, the other features are a result of this extremely atomistic way of organizing experiences. By that, the behaviour is the expression of the extremely atomistic way of organizing experiences. Even if finding the cause or the main feature of autism was not the aim of this study, the results raise new, interesting questions in such a research area.

Acknowledgements

This study was made possible through financial support from the Swedish Research Council. The children, teachers and families in this study have contributed in an important way for which I am also very grateful.

American Psychiatric Association . 1994 . Diagnostic and statistical manual of mental disorders , 4th ed. (DSM-IV) . [city: Washington ] , [state: DC ] : American Psychiatric Association .  

Austin , J. , and J. Carr , 2000 . Handbook of applied behavior analysis . [city: Reno ] : Context Press .  

Baron-Cohen , S. (1995). . Mindblindness: An essay on autism and theory of mind . , [city: Cambridge ] , [state: MA ] : : MIT Press. .  

Bransford , J. and Schwartz , D. (1999). . Rethinking transfer: A simple proposal with multiple implications . Review of Research in Education, a Publication of the American Educational Research Association , 24: : 61.–.  

Brown , A.L. (1992). . Design experiments: Theoretical and methodological challenges in creating complex interventions in classroom settings . The Journal of the Learning Sciences , 2((2)): : 141.–.  

Carlgren , I. , and F. Marton . 2002 . Lärare av imorgon [Teachers of tomorrow] . Stockholm : [city: Lärarförbundet ] .  

Cohen , S. (1998). . Targeting autism. What we know, and can do to help young children with autism and related disorders . , [city: California ] : : California University Press. .  

Duvner , T. 1994 . Barnneuropsykiatri. MBD/DAMP, autistiska störningar, dyslexi [Child neuropsychiatry, MBD/DAMP, autistic disorders, dyslexia] . Stockholm : [city: Liber Utbildning ] .  

Frith , U. (1989). . Autism. Explaining the enigma . , [city: Oxford ] : : Basil Blackwell. .  

Gibson , J. (1986). . The ecological approach to visual perception . , [city: Hillsdale ] , [state: NJ ] : : LEA. .  

Gillberg , C. 1995 . Autism och autismliknande tillstånd hos barn, ungdomar och vuxna [Autism and autism related states by children, teenagers and adults] . [city: Stockholm ] : Natur och Kultur .  

Grandin , T. (1986). . Emergence labelled autistic . , [city: California ] : : Arena Press. .  

Gray , C. 1995 . Teaching children with autism to ‘read’ social situations . In Teaching children with autism , A. Quill , 219 – 241 . [city: New York ] : Delmar Publisher .  

Happé , F. (1994). . Autism. An introduction to psychological theory . , [city: Cambridge ] , [state: MA ] : : Harvard University Press. .  

Happé , F. , J. Briskman and U. Frith . 2001 . Exploring the cognitive phenotype of autism: Weak ‘central coherence’ in parents and siblings of children with autism, I. Experimental tests . Journal of Childhood Psychology and Psychiatry 42 3 299 307  

Holmqvist , M. 1995a . Autism. Uppfostran, undervisning och förståelse för personer med extremt atomistisk omvärldsuppfattning [Autism. Bringing up, educating and understanding individuals with extremely atomistic environmental experiences] . Göteborg : [city: Kompendiet ] .  

Holmqvist , M. . 1995b . Autism. Specialpedagogisk träning för utökad social kompetens och omvärldsförståelse. [Autism. Special educational training to enhance social competence and environmental understanding] Nordisk Tidskrift för Specialpedagogik 4 174 81  

Holmqvist , M. . 1996 . Understanding, bringing up and educating people with autism . LINK Autisme-Europa 18 : 12 – 14  

Holmqvist , M. 2004a . Improving the educational outcomes of disabled children by using a theory of variation at school . Paper presented at Oxford Round Table, March 21–26, in Oxford .  

Holmqvist , M. 2004b . En främmande värld. Om lärande och autism [A strange world. Learning and austim] [city: Lund ] : Studentlitteratur .  

Holmqvist , M. , L. Gustavsson , and A. Wernberg . 2008 . Variation theory – An organizing principle to guide design research in education In Handbook of design research methods in education , M. Holmqvist , L. Gustavsson , and A. Wernberg , 111 – 30 . [city: New York ] Routledge .  

Howlin , P. (1998). . Children with autism and Asperger syndrome. A guide for practitioners and carers . , [city: Chichester ] : : Wiley. .  

Howlin , P. , S. Baron-Cohen , and J. Hadwn . 1999 . Lära barn med autism att läsa andras tankar och känslor [Teaching children with autism to mind-read] [city: Stockholm ] : Cura .  

Jordan , R. and Powell , S. (1995). . Understanding and teaching children with autism . , [city: Chichester ] : : Wiley. .  

Kanner , L. (1943). . Autistic disturbances of affective contact . Nervous Child , 2: : 217.–.  

Kelly , A. , and R. Lesh , 2000 . Handbook of research design in mathematics and science education . [city: London ] : Lawrence Erlbaum Associates .  

Lovaas , I. and Buch , G. (1997). . “Intensive behavioural intervention with young children with autism ”. In Prevention and treatment of severe behaviour problems: Models and methods in developmental disabilities . , Edited by: Singh , N.N.   [city: Pacific Grove ] , [state: CA ] : : Books/Cole. .  

Lord , C. and P. McGee 2001 . Educating children with autism . [city: Washington ] : National Academic Press, National Research Council .  

Marton , F. (2000). . The practice of learning . Nordisk Pedagogik , 4: : 230.–.  

Marton , F. and Booth , S. (1997). . Learning and awareness . , [city: Mahwah ] , [state: NJ ] : : Lawrence Erlbaum Associates. .  

Marton , F. , and P.M. Fai . 1999 . Two faces of variation . Paper presented at the 8th European Conference for Learning and Instruction August 24–28at Göteborg University , Sweden. http://www.ped.gu.se/biorn/phgraph/civil/graphica/newph.html .  

Marton , F. , and K. Trigwell . 2000 . Variatio Est Mater Studiorum . Higher Education Research and Development 19 3 381 – 95 .  

Marton , F. and Tsui , A. (2004). . Classroom discourse and the space of learning . , [city: London ] : : Lawrence Erlbaum Associates. .  

Marton , F. and Tsui , A. (2004). . Classroom discourse and the space of learning . , [city: Mahwah ] , [state: NJ ] : : Lawrence Erlbaum Associates. .  

McClannahan , L. and Krantz , P. (1999). . Activity schedules for children with autism . , [city: Bethesda ] , [state: MD ] : : Woodbinehouse. .  

McNiff , J. and Whitehead , J. (2005). . Action research for teachers. A practical guide . , [city: London ] : : David Fulton Publishers Ltd. .  

Quill , K. (1995). . Teaching children with autism. Strategies to enhance communication and socialisation . , [city: New York ] : : Delmar Publishers Inc. .  

Reynhout , G. and Carter , M. (2006). . Social stories for children with disabilities . Journal of Autism and Developmental Disorders , 36: : 445.–.  

Rubin , E. 1915 . Synoplevende figurer, studier i psykologisk analyse, forste del [Visual based figures, studies in psychological analysis, the first part] . [city: Köpenhamn ] : Gyldendalsk .  

Runesson , U. 1999 . Variationens pedagogik. Skilda sätt att behandla ett matematiskt innehåll [The pedagogy of variation] . [city: Göteborg ] : Acta Universitatis Gothoburgensis .  

Russell , J. 1997 . Autism as an executive disorder . [city: Oxford ] : Oxford University Press .  

Schopler , E. and Mesibov , G. (1995). . Learning and cognition in autism . , [city: New York ] : : Plenum Press. .  

Schwartz , D. , and J. Bransford . 1998 . A time for telling . Cognition and Instruction 16 4 475 – 522 .  

Tomal , D. (2003). . Action research for educators . , [city: Oxford ] : : Rowman and Littlefield Education. .  

Tomasello , M. (1999). . Human cognition . , [city: London ] : : Harvard University Press. .  

Vygotskij , L. (1997). . Educational psychology . , [city: Boca Raton ] : : St. Luge cop. .  

Wertheimer , M. (1959). . Gestalt psychology: Thought and thinking . , [city: New York ] : : Harper. .  

Wing , L. (1996). . The autistic spectrum: A guide for parents and professionals . , [city: London ] : : Constable. .  

Academia.edu no longer supports Internet Explorer.

To browse Academia.edu and the wider internet faster and more securely, please take a few seconds to  upgrade your browser .

Enter the email address you signed up with and we'll email you a reset link.

• We're Hiring!
• Help Center

Download Free PDF

Psychology Case Study on Autism

Related papers

Journal for ReAttach Therapy and Developmental Diversities, 2020

Introduction: Autism spectrum disorder (ASD) is a complex neurodevelopmental condition that occurs within the first 3 years of life, which is characterised by poor social skills, communication problems and stereotyped patterns of behaviour. Autism is a lifelong disorder that has a substantial effect on the individual, their family, and society. The purpose of this paper is to provide an overview about the psychosocial aspects of autism spectrum disorders. Methods: An analysis of relevant literature, sources from the internet and published literature, personal experience and observations of the author. Findings: Despite widespread research and greater public awareness, ASD has an unclear etiology and no known cure, making it difficult to acquire an accurate and timely diagnosis. Psychologic functions such as attention , executive function, academic functioning, memory, emotions, and sensory processing are described. There is a need for continuous psycho-social support for people with ASD and their relatives during the diagnostics and early intervention period, as well as resources that better represent the diversity of experiences and symptoms associated with ASD across the lifespan. Conclusion: It is clear that more special education services are needed, together with timely and ongoing psy-chosocial support to parents of children with ASD.

Autism Spectrum Disorder (ASD) is a complex neurodevelopmental condition that is marked by both social and cognitive impediments (Lipinski et al., 2019). Currently, about 1% of the population in North America will meet the diagnostic criteria for ASD (Schmidt et al., 2015). With a few rare exceptions, the majority of individuals with this diagnosis require ongoing support and care (Schmidt et al., 2015). In addition to the challenges associated with the disorder, there is a high rate of comorbidity amongst the ASD community, indicating the need for skilled intervention (Lipinski et al., 2019). However, there are few psychotherapists who are trained to work with this population. In light of these growing concerns, the following paper will explore how clinicians can offer effective, evidence-based interventions for client’s with ASD. In particular, the exercise will address diagnostic criteria, development and course, etiology, epidemiology, diagnostic issues, prognosis, assessment, and theoretical treatments.

This article aims to observe all the manifestations of the behavior of a child with Autism Spectrum Disorder (ASD), which shows deficits mainly in the communication sector. Also, the child shows repetitive and stereotypical behaviors throughout the lesson (Stasinos, 2016). Initially the paper describes the methodology followed. It then describes the child's cognitive profile and the deficits he presents. He then analyzes the intervention that was applied in order to improve the difficulties he faces and to further strengthen the skills he has already acquired. Finally, the paper presents the main conclusions as they emerged from the intervention.

Contents: Foreword. Preface. Part I: The Study of Autism: Perspectives of a Field in Transition. J.D. Bregman, Definitions and Characteristics of the Spectrum. L.Y. Tsai, Recent Neurobiological Research in Autism. V.M. Durand, Past, Present, and Emerging Directions in Education. A. Hecimovic, S. Gregory, The Evolving Role, Impact, and Needs of Families. Part II: The Early Years. E.M. Gabovitch, N.D. Wiseman, Early Identification of Autism Spectrum Disorders. J. Scott, W.L. Baldwin, The Challenge of Early Intensive Intervention. J.S. Bloch, J. Weinstein, M. Seitz, School and Parent Partnerships in the Preschool Years. Part III: Educational Programming, Interventions, and Medical Treatment for Persons With Autism. J.S. Handleman, L.M. Delmolino, Assessment of Children With Autism. D. Zager, N. Shamow, Teaching Students With Autism Spectrum Disorders. A.M. Wetherby, B.M. Prizant, Enhancing Language and Communication Development in Autism Spectrum Disorders: Assessment and Intervention ...

Malaysian Journal of Public Health Medicine, 2018

Children with Autism Spectrum Disorder (ASD) have significant challenges in their daily life including social communication and interaction, emotional awareness and management, as well as behavioural issues. Many interventions are conducted based on theoretical backgrounds and past literature. There is lack of research study that interview and explore the real psychological needs of children with ASD in Malaysia. It is a significant component as their needs may vary depending on the cultural background, lifestyle, and social norms. Besides, there is a need to develop standardised intervention module to enhance intervention fidelity and replication of future study. The current study aims to scrutinise the psychological needs of children with ASD in Malaysia, develop a standardised group intervention module based on the identified needs, and then examine the feasibility of the developed module. Nine children with moderate to high functioning of ASD (7 to 12 years old) and their parent...

European Journal of Special Education Research, 2019

The purpose of this study is to present a case report of an autism incident, specifically of a toddler's, and of an educational intervention program that was built in order to promote his inclusion in the group and to compensate for adjustment difficulties. The paper presents a description of an educational experience through presentation of an autism incident and the analysis of the educational intervention and strategies followed. In particular, the educational intervention was implemented in a Centre for the design and implementation of personalized and group education programs, which creates a variety of social stimuli of inclusion philosophy towards the child and the design and implementation of each program is based on working with the family. Overall, various forms of organizing the education of the child with autism were intentionally used, due to the variety of special educational needs which appear in this category of children and flexible access to a wide range of opportunities required. Finally, it should be noted that after the daily review of child performance data and decision-making on the part of the educator, on the teaching strategy that was being promoted each time, this child had obvious progress in the way of approaching and communicating within the team, as well as in issues of self-service, as well as fine and tangible mobility. Apparently, his communication and social skills have been improved to a good extent and his inclusion has proved to be a realistic goal in the context of this systematic pedagogical intervention.

Zenodo (CERN European Organization for Nuclear Research), 2021

Loading Preview

Sorry, preview is currently unavailable. You can download the paper by clicking the button above.

Neuropsychology Review, 2008

Boletín médico del Hospital Infantil de México

CoDAS, 2013

Advances in Neurodevelopmental Disorders, 2019

IntechOpen eBooks, 2023

Khatija Tul Kubra, 2024

International Journal of Social Science Research, 2020

"An Attempt to Get Acquainted with Autism Spectrum Disorders". EC Psychology and Psychiatry 8.12(2019): 01-04, 2019

Journal of Early Intervention, 2011

Social Science Research Network, 2021

… and Training in …, 2007

Autism Spectrum Disorder - Recent Advances, 2015

National Center For Special Education Research, 2007

Journal of the American Academy of Child and Adolescent Psychiatry, 1999

Research in Autism Spectrum Disorders, 2009

•   We're Hiring!
•   Help Center
• Find new research papers in:
• Health Sciences
• Earth Sciences
• Cognitive Science
• Mathematics
• Computer Science
• Academia ©2024

Are Social Stories for Autistic Children Effective?

A mother's insight into using social stories with a child who has autism..

Posted October 17, 2024 | Reviewed by Jessica Schrader

• What Is Autism?
• Find counselling to help with autism
• Social stories can be helpful in expanding children's understanding of a situation.
• Social stories are tailored to the uniqueness of a child, their caregivers and community, and the context.
• Social stories are difficult to evaluate, but research in the last decade demonstrated higher quality.

Social stories have been a constant companion in my parenting journey (with my two neurodivergent boys).

I, as well as our speech and occupational therapists, crafted social stories whenever we wanted to expand my boys’ understanding about which behaviors were safe and nourishing (which we wanted them to choose) and which ones were less safe and associated with greater discomfort and distress (which we wanted them to stop engaging in, or at least decrease). Or, we crafted social stories to break down instructions about how to perform a task, for instance how to play a “Guess Who” game with a friend, or how to play with trucks at the sand pit on a play date.

The social stories we crafted always involved explicit descriptions of various situations and addressed a myriad of "wh" questions; you know the ones: who, what, where, when, why, and how. They also included photos that my boys loved looking at. I loved seeing their reactions, "It's my picture!” “It's a book about me!" Personally, we found social stories incredibly effective, hence I continued using them over the years.

For instance, when we welcomed a new puppy into our home, a social story crafted by our speech therapist helped to clarify what behaviors were safe and nurturing toward the puppy. It outlined ideas for appropriate play and gentle handling, while also explaining that when a puppy barks, it is likely communicating that he doesn’t like what we are doing and would like us to be gentler. At other times, he may bark to get our attention , say hello, or be guarding our space.

Another social story crafted by our occupational therapist taught my boys to not run away from their granddad when they were out and about with him, at a trying time when they were testing their independence, as he cannot chase them. I also recall our occupational therapist crafting an incredibly effective social story for teaching my little one to not demand that we say a phrase repeatedly in a very precise way, or else… (he would feel distressed).

One of my favorite social stories was one I crafted about sharing toys, at a time my youngest was approaching an age where he felt curious about his big brother’s things and enjoyed reaching for them. Desperate to ease the occasional outbursts of temper that flared from the resultant shifts in boundaries , the social story outlined specific strategies for "sharing management ," and was quite effective for our situation. While it wasn’t a miraculous cure for easing all of our frustrations around sharing, it was a resource that we returned to, over and again, that afforded us greater control and clarity over managing this situation.

I continue to make use of various social stories to help my own children and my little clients find ways to respond to their feelings, for instance expanding their awareness about appropriate and inappropriate responses for managing frustration.

Despite finding social stories personally invaluable, evaluating their effectiveness can be challenging. Social stories, by definition, are unique and tailored to an individual child, their family, and their environment, making comparisons difficult. In addition, they are delivered by unique individuals with various flavors of engagement and differences in the way they administer social stories. These include differences in joint attention and expression of encouragement and positive reinforcement. Social stories can also be delivered in many ways, such as via iPad, paper copy, audio, or video, and can vary in the quality of formatting, illustrations, and photos, and in how much these resonate with the child’s inner experience and understanding of a situation.

Many studies report positive outcomes associated with the use of social stories, including when social stories are administered by parents (Camilleri et al., 2022). These are usually measured via changes in the child's behavior (that is targeted in the social story). Camilleri et al. (2022) indicated that there has been an overall improvement in the quality of research regarding social stories within the last decade or so, which has been accompanied by an overall increase in reports of the effectiveness of social stories for autistic children (Karal & Wolfe, 2018; Qi et al., 2018; Aldabas, 2019). However, Camilleri et al. (2022) generally concluded that "further research is needed," in response to generally mixed findings regarding the strength of the effectiveness of social stories. It would be helpful to better understand what variables influence the effectiveness of social stories, in what settings, and for what individuals.

If you're looking to write your own social story, consider following the criteria of Carol Gray, an expert in this area, whose published work on this topic originated in the 1990s. Her latest comprehensive criteria for crafting social stories are available via her website (see the references section).

In general, Gray recommends that social stories:

• Include clear goals about the information they would like to share, in a meaningful and safe manner.
• Include details that are specific and relevant to the child’s circumstances and experience and, hence, are meaningful to them.
• Have structure including an introduction to the topic, a main body, a conclusion, and an overall summary.
• Use first or third-person language, while answering "wh" questions (who, what, where, when, why, how). This helps to keep the sentences within the social story descriptive rather than general. For instance, instead of saying "I go to the shop," a descriptive sentence may be "Mom and I go to Walmart every Saturday morning to do a big shop for the week.”

Personally, I like to take matters into my own hands and test whether, for the purposes I am crafting a social story, it is having an impact. You, too, can be your own researcher and gather data before you introduce a social story, in between its various presentations, as well as at follow-up. Given the uniqueness of you, your child, and the social story, it may be the most effective way to see whether it will have an impact. Happy writing.

Comparison of Social StoriesTM 10.0 – 10.2 criteria . carolgraysocialstories.com/wp-content/uploads/2015/09/Social-Stories-10.0-10.2-Comparison-Chart.pdf (Accessed: 17 October 2024).

Camilleri, L. J., Maras, K., & Brosnan, M. (2022). Autism Spectrum Disorder and Social Story Research: a Scoping Study of Published, Peer-Reviewed Literature Reviews. Review Journal of Autism and Developmental Disorders , 9 (1), 21–38. https://doi.org/10.1007/s40489-020-00235-6

Bozena Zawisz is a psychologist and award-winning author specializing in psycho-educational resources for young Autistic persons and mindful journaling interventions for women.

• Find a Therapist
• Find a Treatment Center
• Find a Psychiatrist
• Find a Support Group
• Find Online Therapy
• International
• New Zealand
• South Africa
• Switzerland
• Asperger's
• Bipolar Disorder
• Chronic Pain
• Eating Disorders
• Passive Aggression
• Personality
• Goal Setting
• Positive Psychology
• Stopping Smoking
• Low Sexual Desire
• Relationships
• Child Development
• Self Tests NEW
• Therapy Center
• Diagnosis Dictionary
• Types of Therapy

It’s increasingly common for someone to be diagnosed with a condition such as ADHD or autism as an adult. A diagnosis often brings relief, but it can also come with as many questions as answers.

• Emotional Intelligence
• Gaslighting
• Affective Forecasting
• Neuroscience

IEEE Account

• Change Username/Password
• Update Address

Purchase Details

• Payment Options
• Order History
• View Purchased Documents

Profile Information

• Communications Preferences
• Profession and Education
• Technical Interests
• US & Canada: +1 800 678 4333
• Worldwide: +1 732 981 0060
• Contact & Support
• About IEEE Xplore
• Accessibility
• Terms of Use
• Nondiscrimination Policy
• Privacy & Opting Out of Cookies

A not-for-profit organization, IEEE is the world's largest technical professional organization dedicated to advancing technology for the benefit of humanity. © Copyright 2024 IEEE - All rights reserved. Use of this web site signifies your agreement to the terms and conditions.

Log in using your username and password

• Search More Search for this keyword Advanced search
• Latest content
• Current issue
• For authors
• BMJ Journals

You are here

• Online First
• Comparison of clinical presentation and management of children and adolescents with ARFID between paediatrics and child and adolescent psychiatry: a prospective surveillance study
• Article Text
• Article info
• Citation Tools
• Rapid Responses
• Article metrics

• Ellaha Haidar 1 ,
• http://orcid.org/0000-0001-9329-5335 Javier Sanchez-Cerezo 1 , 2 ,
• Josephine Neale 1 , 3 ,
• Nikita Julius 1 ,
• http://orcid.org/0000-0001-8474-7459 Richard Lynn 4 ,
• Lee D Hudson 4 ,
• http://orcid.org/0000-0001-7257-6605 Dasha Nicholls 1
• 1 Department of Brain Sciences , Imperial College London , London , UK
• 2 Department of Psychiatry , Puerta de Hierro University Hospital of Majadahonda , Madrid , Spain
• 3 Priory Hospital Ticehurst House , Ticehurst , UK
• 4 University College London Institute of Child Health , London , UK
• Correspondence to Dr Javier Sanchez-Cerezo; j.sanchez-cerezo{at}imperial.ac.uk

Objective To compare the clinical presentations, management and outcomes of avoidant/restrictive food intake disorder (ARFID) across paediatric and child and adolescent (C&A) psychiatric settings.

Study design Prospective surveillance study.

Methods Data were collected during a 13-month prospective surveillance study of children and adolescents with ARFID in the UK and Republic of Ireland. Paediatricians reported cases via the British Paediatric Surveillance Unit and psychiatrists through the Child and Adolescent Psychiatry Surveillance System. A follow-up questionnaire was sent at 12 months after a case of ARFID was reported.

Results 319 cases were included, 189 from paediatricians and 130 from C&A psychiatrists. Patients presenting to paediatricians were younger (9.8 years vs 13.7 years), more often male (62.4% vs 43.1%), and had more chronic symptoms (80.4% vs 67.0%), selective eating (63.7% vs 46.6%) and comorbid autism (67.6% vs 50.0%) than to psychiatrists. Psychiatrists saw patients with more fear of aversive consequences from eating (13.1% vs 3.2%), weight loss (76.7% vs 65.0%) and comorbid anxiety (78.2% vs 47.4%). Patients presenting to paediatricians more often received medical monitoring (74.6% vs 53.1%), dietetic advice (83.1% vs 70.0%) and nutritional supplements (49.2% vs 30.0%). At follow-up, both cohorts improved in nutritional status. However, the psychiatric cohort improved more regarding disordered eating behaviours.

Conclusions The presentation and management of ARFID differs across clinical settings. Findings suggest the need to develop clinical pathways for ARFID assessment and management across paediatrics and mental health. Our findings highlight the potential benefits of psychiatric input for some patients with ARFID.

• Child Psychiatry
• Paediatrics
• Epidemiology
• Adolescent Health

Mental health

Data availability statement.

Data are available upon reasonable request. Deidentified participant data that underlie the results reported in this article can be shared upon specific requests by researchers who provide a methodologically sound proposal. The proposal will be considered by the investigators of this article. Requests should be directed by email to the corresponding author.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/archdischild-2024-327032

Statistics from Altmetric.com

Request permissions.

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

WHAT IS ALREADY KNOWN ON THIS TOPIC

Avoidant/restrictive food intake disorder (ARFID) is an eating disturbance which leads to: weight loss; nutritional deficiency; dependence on enteral feeding/nutritional supplements; or psychosocial impairment.

ARFID is an umbrella term covering a number of clinical presentations. Existing descriptions of ARFID presentations have drawn from specific clinical settings, limiting their generalisability.

Clinical guidance on the management of ARFID is limited by a lack of research evidence.

WHAT THIS STUDY ADDS

This is the first study to examine the presentation and management of ARFID across different clinical settings.

It highlights the potential benefits of collaborative working and availability of psychological interventions in improving outcomes for children and young people with ARFID.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

This will guide the development of evidence-based pathways for ARFID assessment and management to ensure they are tailored to the specific needs of each patient.

Avoidant/restrictive food intake disorder (ARFID) is a persistent eating disturbance resulting in inability to meet nutritional or energy needs. 1 Unlike anorexia nervosa, food restriction is not driven by concerns about weight or body image; instead, three primary rationales behind food restriction in ARFID have been proposed, including: sensitivity to sensory aspects of food; lack of interest in eating; and fear of aversive consequences (eg, choking, vomiting). 1 2 These presentations may occur independently or coexist, and differ by age and sex, among other factors. 3 Prevalence estimates range from 0.3% and 15.5% in non-clinical settings up to 64% in specialist eating disorder clinics. 4

ARFID frequently presents together with various medical and psychiatric comorbidities, including anxiety, 5 autism spectrum disorder (ASD) 6 or obsessive-compulsive disorder (OCD). 7 Medical sequelae of ARFID can be severe, with multiple potential complications due to low weight and malnutrition. 8

As a relatively new diagnosis, research on ARFID remains limited. Current management strategies are formulated using clinical experience rather than research evidence due to lack of randomised controlled trials. 7 9 Patients with ARFID require assessment and treatment using a multimodal multidisciplinary approach. 10

Existing literature characterising ARFID is highly heterogeneous depending on the clinical setting. Studies have been conducted in paediatric settings 11–15 but, to our knowledge, no previous research has compared clinical presentations and management of ARFID between paediatric and psychiatric settings. We aimed to characterise ARFID presentations in children and young people (CYP) and the care received in each setting. We hypothesised differences in demographic and clinical characteristics, medical symptoms, psychiatric comorbidities, management approaches and outcomes between cases seen in paediatric and psychiatric services.

Study design

Data were from a prospective surveillance study of CYP with ARFID in the UK and the Republic of Ireland (ROI) presenting to secondary care. The study was undertaken over 13 months, 1 March 2021 to 31 March 2022, with 1-year follow-up. Cases were identified through the British Paediatric Surveillance Unit (BPSU) and the Child and Adolescent Psychiatry Surveillance System (CAPSS), which employ active surveillance methodology to facilitate research into rare paediatric conditions. 16 Surveillance report cards were emailed monthly to 4298 consultant paediatricians and 695 child and adolescent psychiatrists, requesting notification of new cases meeting ARFID reporting criteria. A 1-year follow-up questionnaire was then sent to clinicians reporting confirmed cases.

Study population

Participants were CYP newly diagnosed with ARFID attending secondary care. A surveillance case definition ( online supplemental table 1 ) based on modified Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria 1 was approved by BPSU and CAPSS committees. Paediatricians reported cases from 5 to 16 years as indicated in BPSU guidelines. 17 Psychiatrists reported cases from 5 to 18 years. Clinicians reporting a suspected case received a questionnaire requesting more information. A detailed analytical case definition was used by the study team to confirm cases based on the questionnaire data ( online supplemental table 2 ).

Supplemental material

Data were collected using initial and follow-up questionnaires developed for this study by the authors. All data were depersonalised using Research Electronic Data Capture (REDCap), 18 a secure, web-based software platform, and stored in a protected environment at Imperial College London. Questionnaires included items on demographic, presentation, clinical features and management of each case using yes/no questions supplemented with free text or multiple-response options. Additionally, clinicians were asked to report their overall clinical impression regarding the patient’s eating behaviours at follow-up. We compared responses between paediatricians and psychiatrists.

Body mass index (BMI) was calculated and z -scores for height, weight and BMI were determined using UK 1990 growth reference data. 19 20 BMI z-score cut-offs were: obesity >+2 SD; overweight >+1 to ≤+2 SD; normal weight ≤+1 SD to >−2 SD; underweight ≤−2 to >−3 SD; and severe underweight <−3 SD. 21

We classified cases using four mutually exclusive ARFID subtypes defined elsewhere (Combined, Sensory, Lack of interest, Fear). 3

Data were coded and analysed with IBM Statistical Package for Social Sciences (SPSS) V.29.0. For continuous outcomes, Mann-Whitney U test and t-tests were used. Categorical outcomes were evaluated with χ 2 and McNemar’s tests. Statistical significance was set as two-sided p<0.05. As the age range for paediatric cases and psychiatric cases differed, a sensitivity analysis excluding individuals ≥16 years was performed. 18

319 cases of ARFID fulfilled analytical case definition and were included in this study. Of those, 189 cases were reported by paediatricians and 130 by psychiatrists. 265 cases were reported from England, 7 from Wales, 13 from Scotland, 7 from Northern Ireland, 6 from ROI and one each from Jersey and the Isle of Man. Four confirmed cases were reported to both BPSU and CAPSS (duplicates, figure 1 ). Follow-up data were available for 197 (61.8%) participants (113 from paediatricians and 84 from psychiatrists).

• Download figure
• Open in new tab
• Download powerpoint

Flow diagram of case ascertainment. This figure shows the flow of individuals from notification to case validation: after reporting a case to BPSU or CAPSS, clinicians were contacted to complete a questionnaire. Reporting errors (such as prevalent cases or confirmed diagnosis of anorexia nervosa) were excluded prior to baseline questionnaire completion after contacting the clinician. Unable to follow-up cases were those excluded due to clinicians stating that they did not wish to be included in the study (due to retirement, shortage of reporting capacity and so on). Cases were excluded if no response was obtained after multiple attempts to contact the notifying clinician or their team (no baseline data received). Completed questionnaires by reporting clinicians were examined to confirm cases were eligible for inclusion. Duplicates were identified and excluded. Additional cases from other sources that met inclusion criteria were added. A 1-year follow-up questionnaire was sent to clinicians reporting confirmed cases. BPSU, British Paediatric Surveillance Unit; CAPSS, Child and Adolescent Psychiatry Surveillance System.

Demographics

Table 1 summarises demographic characteristics. 174 (54.5%) male and 145 (45.5%) female cases were reported. Paediatricians were significantly more likely to see males than psychiatrists (χ 2 (1, n=319)=11.64, p=0.001, ϕ=0.19). The median age of participants was 11.9 years (IQR 7.6, 14.4). Individuals in the psychiatric cohort had a higher median age (13.7 years; IQR 10.5, 15.1) compared with the paediatric cohort (9.8 years; IQR 6.5, 13.2; U=17 103, z=5.95, p<0.001, r=0.33). Paediatricians more often managed children aged 5–9 years, whereas psychiatrists more so treated CYP aged 10–14 and 15–18 (χ 2 (2, n=319)=31.97, p<0.001, ϕ=0.32). Psychiatrists were more likely to see white British CYP, while paediatricians saw more from African, Caribbean, black British and other ethnic backgrounds (χ 2 (5, n=295)=14.46, p=0.013, ϕ=0.22). Duration of symptoms at presentation ranged from 0 to 16 years, with a median of 3.0 years (IQR 0.9, 6.0). CYP with longer duration of symptoms more frequently presented to paediatricians (χ 2 (1, n=272)=6.25, p=0.012, ϕ=0.15).

• View inline

Paediatric cases (79 (41.8%)) were more likely to present with Combined subtype than psychiatric cases (43 (33.1%)). Psychiatrists reported a higher proportion of CYP with Fear subtype (17 (13.1%)) than paediatricians (6 (3.2%); χ 2 (3, n=319)=13.00, p=0.005, ϕ=0.20).

Clinical presentation

Clinical characteristics are shown in table 2 . 53.4% participants were normal weight, 34.2% underweight and 12.3% overweight or obese at presentation. Paediatricians were more likely to report overweight CYP (18 (13.0%)) than psychiatrists (2(2.1%); χ 2 (4, n=234)=10.29, p=0.036, ϕ=0.21) and mean SD BMI z -scores were lower in psychiatry settings (−1.70 (1.76)) than in paediatrics (−0.99 (1.79); t(232)=3.02; p=0.003; ɳ 2 =0.037). A higher proportion of cases presented with weight loss in the psychiatric cohort (99 (76.7%)) than the paediatric cohort (119 (65.0%); χ 2 (1, n=312)=4.93, p=0.026, ϕ=0.13). Paediatric cases (92 (50%)) were more frequently prescribed nutritional supplements than psychiatric cases (46 (37.4%); χ 2 (1, n=307)=4.73, p=0.030, ϕ=0.12), most commonly for iron and vitamin D deficiencies. The paediatric cohort also exhibited a higher tendency to exclude whole food groups (‘selective eating’) (116 (63.7%)) compared with those presenting to psychiatry (55 (46.6%); χ 2 (1, n=300)=8.57, p=0.003, ϕ=0.17).

Constipation (70 (21.9%)) was the most prevalent medical symptom/sign, followed by dizziness (56 (17.6%)), bradycardia (15 (14.4%)) and muscle wasting (26 (8.2%)). The psychiatric cohort (36 (27.7%)) experienced dizziness significantly more than the paediatric cohort (20 (10.6%); χ 2 (1, n=319)=15.58, p<0.001, ϕ=0.22). The paediatric cohort (53 (28.0%)) had higher rates of constipation than the psychiatric cohort (17 (13.1%); χ 2 (1, n=319)=10.07, p=0.002, ϕ=0.18). Menstrual status was reported in 28 of 145 females (19.3%). Of these, 10 (35.7%) had documented secondary amenorrhoea, 5 (33.3%) in the paediatric and 5 (38.5%) in the psychiatric cohort.

The psychiatric cohort were more likely to be reported as having comorbid anxiety (79 (78.2%)), depression (24 (25.5%)) or OCD (14 (15.7%)) than the paediatric cohort (72 (47.4%); χ 2 (1, n=253)=24.00, p<0.001, ϕ=0.31; 9 (6.3%); χ 2 (1, n=237)=17.51, p<0.001, ϕ=0.27; 8 (5.8%); χ 2 (1, n=226)=6.01, p=0.014, ϕ=0.16) and more likely to show deliberate self-harm (16 (17.6%)) than the paediatric cohort (12 (8.4%); χ 2 (1, n=234)=4.46, p=0.035, ϕ=0.14). More children with ASD (96 (67.6%)) and intellectual disabilities (ID) (55 (33.1%)) were reported by paediatricians than psychiatrists (43 (50.0%); χ 2 (1, n=228)=6.98, p=0.008, ϕ=0.18; 10 (10.2%); χ 2 (1, n=264)=17.46, p<0.001, ϕ=0.26).

Median time to diagnose ARFID was significantly higher in paediatric (1.1 months—IQR 0, 17.2) than psychiatric settings (0.5 months—IQR 0, 2.9; U=7568, z=−2.21, p=0.027, r=0.13). Management strategies are described in table 3 . Paediatricians were more likely to provide dietetic advice (157 (83.1%)) and medical monitoring (141 (74.6%)) and to prescribe nutritional supplements (93 (49.2%)) and tube feeding (16 (8.5%)) than psychiatrists (91 (70.0%); χ 2 (1, n=319)=7.60, p=0.006, ϕ=0.15; 69 (53.1%); χ 2 (1, n=319)=15.87, p<0.001, ϕ=0.22; 39 (30%); χ 2 (1, n=319)=11.71, p=0.001, ϕ=0.19; 4 (3.1%); χ 2 (1, n=319)=3.81, p=0.051, ϕ=0.11). Paediatricians drew input from other health professionals more frequently (66 (34.9%)), including dieticians and occupational therapists, than psychiatrists (29 (22.3%); χ 2 (1, n=319)=5.86, p=0.015, ϕ=0.14). Psychiatrists used more psychoeducation (87 (66.9%)) and individual psychological therapy (48 (36.9%)) than paediatricians (77 (40.7%); χ 2 (1, n=319)=21.14, p<0.001, ϕ=0.26; 36 (19.0%); χ 2 (1, n=319)=12.69, p<0.001, ϕ=0.20). Paediatricians referred 75 cases (39.7%) to a psychiatrist or psychologist; psychiatrists referred 11 cases (8.5%) to a paediatrician.

Management strategies

Table 4 displays the changes in nutritional status and eating behaviours after 1-year follow-up. SD BMI z -scores increased from baseline (−1.50 (1.71)) to follow-up (−1.26 (1.81); t(111)=−3.46; p=0.001; ɳ 2 =0.10) for the whole sample. CYP receiving psychiatric care were reported as having greater improvement in overall eating behaviour (57 (81.4%)) than paediatric patients (51 (53.7%); χ 2 (3, n=165)=21.89, p<0.001, ϕ=0.36) ( table 5 ).

Outcomes at 1-year follow-up

Overall clinical impression regarding the patient’s eating behaviours at follow-up

Four cases were reported to both BPSU and CAPSS: two girls and two boys. Median age was 12.8 years (IQR 11.4, 15.3) and median duration of symptoms was 2.4 years (IQR 1.0, 6.8). Three cases (75%) were from England. Three cases (75%) presented with weight loss (mean SD BMI z-score −2.5 (1.5)).

Sensitivity analysis

All results remained statistically significant in the sensitivity analysis except for comorbid OCD and input from other health professionals ( online supplemental material ).

To our knowledge, this is the first study to characterise and compare how ARFID presents in CYP between paediatric and psychiatric services. Our findings reveal that presentations varied by specialty, with distinct cohorts treated in the two settings. Significant differences between specialties included symptom duration, eating behaviours, clinical features, comorbidities, management approaches and long-term outcomes. Our findings serve as a key step towards developing evidence-based management pathways for this patient group.

Compared with psychiatry, the paediatric cohort consisted of more males and younger patients with longer symptom duration and more selective eating, nutritional deficiencies, constipation and higher BMIs. Literature suggests that lacking food diversity over long time periods predisposes individuals to malnutrition, altered bowel habits and weight gain, particularly with exclusion of fruits and vegetables. 22–24 Results suggest that psychiatric teams manage cases with shorter duration of symptoms, often a more acute clinical picture, characterised by anxiety, weight loss and dizziness. This presentation is consistent with prior research on manifestation of acute malnutrition in ARFID, including dizziness and fainting due to dehydration, hypotension or bradycardia 25 which correlates with the rate of weight loss. 26 The age difference between cohorts may be explained by distinct referral pathways, presenting symptoms and comorbidities. The distribution of comorbid psychiatric and neurodevelopmental disorders differed in each setting; cases seen by psychiatric teams reported as having higher rates of comorbid anxiety and depression, while more CYP with ID and ASD are treated within paediatrics. These profiles are consistent with prior research. 6 25 27 28

Despite consensus supporting a multidisciplinary approach, there was little overlap in cases presenting to paediatrics and psychiatry in our sample. Duplicates were more underweight than the general sample, suggesting more acuteness and therefore seen by both specialties; however, firm conclusions cannot be drawn from this small sample. Our data suggest clinicians in each specialty had distinct management approaches and both cohorts improved in rate of reported weight loss, nutritional deficiencies and exclusion of food groups. The psychiatric cohort additionally exhibited significantly greater improvements in disordered eating behaviours. Moreover, more psychiatrists reported case improvement at follow-up by clinical impression. To note, however, paediatricians and psychiatrists may have different perceptions of clinical improvement.

Patients with ARFID presenting to paediatric settings may also benefit from psychiatric services and psychological interventions, and it is important that clinicians identify these CYP. A multimodal medical and mental health approach to ARFID assessment and treatment on an ARFID-specific referral pathway 29 that facilitates access to and close collaboration between paediatrics and psychiatry would improve care of CYP with ARFID.

Strengths and limitations

This is the first study comparing the clinical characteristics of ARFID in CYP accessing paediatric and psychiatric services. Active surveillance methodology enabled ascertainment of national prospective data from paediatricians and psychiatrists in the UK and ROI. This large sample included CYP of different ages and geographical areas, ensuring data were representative. However, in our prospective research design, loss to follow-up may introduce bias in data analysis. The design of the study meant we were unable to compensate for missing data in analyses. Age criteria for paediatric surveillance (5–16) differed from psychiatric surveillance (5–18), possibly accounting for differences between cohorts. A sensitivity analysis, excluding patients ≥16 years, showed our results were robust. We asked clinicians to report their overall clinical impression of patients’ eating behaviours at follow-up but did not ask them to report this at baseline. We may have introduced reporting bias as no comparisons could be made between cohorts at follow-up regarding medical conditions.

This study reveals variations in the presentation and management of newly diagnosed ARFID cases in different clinical settings. CYP in paediatrics presented more frequently with complications of chronic symptoms due to lack of food variety, often associated with comorbid ASD or ID. Psychiatric teams managed more acute presentations of food restriction, with more weight loss, fears of aversive consequences from eating and mental disorders such as anxiety. Patients managed by psychiatrists responded well to psychological interventions, suggesting that all ARFID CYP should be assessed for suitability for this. Results from this study add support to multidisciplinary management of ARFID and collaborative working across paediatrics and psychiatry.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by the West Midlands–Black Country Research Ethics Committee (Integrated Research Application System ID 273665; REC 20/WM/0256). Due to the nature of the study, using surveillance methodology, patient and parental consent was not required. As consent was not sought and minimal identifier data were required, approval under England and Wales Section 251 via Confidentiality Advisory Group of the Health Research Authority (20/CAG/0120) was obtained. Data were collected in Scotland following advice from the Public Benefit and Privacy Panel for Health and Social Care (HSC-PBPP) (2021-0113). Northern Ireland Privacy Advisory Committee requirements were met to collect data.

Acknowledgments

Our thanks go to all the busy paediatricians and child and adolescent psychiatrists who participated in the surveillance and reported cases and to the charities Autistica and ARFID Awareness UK for supporting the study.

• American Psychiatric Association
• World Health Organization
• Sanchez-Cerezo J ,
• Julius N , et al
• Nagularaj L ,
• Gledhill J , et al
• Nicely TA ,
• Lane-Loney S ,
• Masciulli E , et al
• Strudwick K , et al
• Kambanis PE ,
• Kuhnle MC ,
• Wons OB , et al
• Fisher MM ,
• Ornstein RM , et al
• Thomas JJ ,
• Lawson EA ,
• Micali N , et al
• Archibald T ,
• Hembry P , et al
• Hastings E , et al
• Katzman DK ,
• Spettigue W ,
• Agostino H , et al
• Goldberg HR ,
• Allen L , et al
• Schöffel H ,
• Hiemisch A ,
• Kiess W , et al
• Bertrand V ,
• Tiburce L ,
• Sabatier T , et al
• British Paediatric Surveillance Unit
• Harris PA ,
• Thielke R , et al
• Freeman JV ,
• Chinn S , et al
• Arimond M ,
• Chan JSH , et al
• Van De Water AL ,
• Kuhnle MC , et al
• Białek-Dratwa A ,
• Szymańska D ,
• Grajek M , et al
• Balasundaram PSP
• Bujoreanu S , et al
• Brigham KS ,
• Eddy KT , et al
• Bryant-Waugh R ,
• Munuve A , et al

EH and JS-C are joint first authors.

X @JaviSanCer1, @DashaNicholls

Contributors DN conceptualised the study. DN, JS-C, JN, RL and LDH contributed to the design and development of the study. EH and JS-C performed the analysis and drafted the manuscript. JS-C, JN and DN accessed and verified the data underlying the study. EH and JS-C contributed equally to this paper. All authors edited and approved the final version of the article. All authors confirmed that they had full access to all the data in the study and accepted responsibility to submit for publication. JS-C is the guarantor of this manuscript and accepted full responsibility for the work and conduct of the study, had access to the data and controlled the decision to publish.

Funding This study was funded by the Former EMS Ltd (charity number 1098725, registered 9 Oct 2017). JS-C is supported by a Fellowship funded by the Fundación Alicia Koplowitz. DN is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration Northwest London and the NIHR Imperial Biomedical Research Collaboration.

Disclaimer The views expressed are those of the author(s) and not necessarily those of the NIHR, the Department of Health and Social Care, NHS England and NHS Improvement.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Read the full text or download the PDF: