Middle Childhood

Middle childhood is the period between early childhood and adolescence, the approximate age range of six to twelve years old, but dependent on the onset of puberty and adolescence. This coincides with the primary school phase of education. In this time the child begins to distance from the family physically and emotionally and establish important relationships with peers and other adults outside of the family unit (Slentz & Krogh, 2001). Children are faced with the challenges of navigating the complexities of school life such as the structured environment of academic learning, classroom/school processes, relationships and increasing independence (Slentz & Krogh, 2001). Peer relationships become more important to the child and necessitate more sophisticated social skills (Slentz & Krogh, 2001). Externalised and internalised behaviours may develop or become problematic in nature (Carr, 2015). Normal cognitive development is a critical factor in all these areas, thus children with executive dysfunction may potentially become increasingly challenged during the middle childhood phase (Carr, 2015).

Autism Spectrum Disorder 

Autism Spectrum Disorder (ASD) is described in the American Psychiatric Association’s (2013b) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a condition in which the individual exhibits multiple deficits in the two core domains of social communication and restricted, repetitive sensory-motor behaviour (Lord et al., 2018; Sharma et al., 2018). It is a broad category which has drawn together developmental disorders with significant differences in presentation and severity of symptomology into one diagnostic grouping that is identified as a spectrum (Sharma et al., 2018). The onset of these traits is in the early developmental phase; however, the behavioural characteristics may not be identified until the child enters the school environment and has difficulty managing the routine changes and peer relationships (Volkmar et al., 2014). The child may exhibit behaviours such as restricted, repetitive body movements or interests, deficits in social interaction including lack of eye contact, little variation in facial expression or inability to engage in reciprocal conversation, an inability to recognise another person’s emotions, high anxiety levels and inability to cope with change (Sharma et al., 2018). This list is not definitive, but some of the common and recognisable behaviours. Woodbury-Smith and Scherer (2018) identified a prevalence rate for autism as 1% of the population, with a high rate of co-occurrence for other neurodevelopmental and psychiatric disorders. Males are four times more likely to be diagnosed with ASD than females (Woodbury-Smith & Scherer, 2018). While there are biological alterations to brain development and neurological organisation, the diagnosis of ASD is made based on exhibited social and sensory-motor behaviours (Lord et al., 2018).

Evidence of Symptoms 

ASD presents through a variety of cognitive, behavioural and social symptoms with varying degrees of severity and impact on the ability to function. While these symptoms are typically identified in early development, it is possible for some children to progress normally, and then display signs of regression such as in Rett syndrome (Volkmar et al., 2014). Cognitive symptoms have a significant impact on the skills of the child in social communication and social interactions. The executive functioning of the brain is impaired, resulting in a child having difficulty with multi-tasking type behaviours, such as ability to listen to the teacher and complete a task (Volkmar et al., 2014). This impairment impacts on the ability to engage in theory of mind, thus an ASD child will demonstrate a lack of empathy and inability to recognise another’s perspective, and may exhibit inappropriate emotional responses (Volkmar et al., 2014). A child with ASD can display skill deficits and/or a lack of interest in establishing relationships with peers and engaging in social play. They have difficulties adjusting to different social contexts, do not understand imaginative play or the skills associated with friendship (Lord et al., 2018; Volkmar et al., 2014). The child may have a very limited understanding and use of non-verbal communication skills, with limited or no eye contact, restricted facial expressions and unusual body posture (Sharma et al., 2018).

In 50% of ASD diagnoses, there is an associative diagnosis of intellectual disability (Woodbury-Smith & Scherer, 2018). Language development delays are a common symptom of ASD, with some children being mute (Sharma et al., 2018). Poor expressive language is also common, with children having difficulty initiating or sustaining conversation, and/or with repetitive language patterns evident (Volkmar et al., 2014). Children with the ASD subtype previously referred to as Asperger’s Disorder may present with exceptional language skills for their age; however, it is often very formal and pedantic in its structure, with the child highly focused on favoured topics (Volkmar et al., 2014). Gross motor skills are often poorly developed (Carr, 2015).

Repetitive body movements or activity (such as lining up toys, fiddling with an object) which can also serve as self-stimulating behaviours are a typical pattern of behaviour (Lord et al., 2018; Sharma et al., 2018). Inflexibility in routines, transitions and difficulty coping with change can lead to tantrums, tics and displays of aggression or withdrawal (Lord et al., 2018; Sharma et al., 2018). Children may experience atypical reactions to sensory stimulus in the environment, such as intolerance of sounds or textures in food or clothes, inability to experience pain or identify temperature changes (Lord et al., 2018).

Assessment of a child presenting with ASD type behaviours would involve discussions with the parents and teaching staff working with the child to identify if the child has symptoms typical of ASD and gain some background knowledge. The Autism Spectrum Rating Scale (ASRS; Goldstein & Naglieri, 2010; Department of Education, 2021) would be an appropriate assessment administered by the ASRS trained school Guidance Officer, under the direct supervision of the Senior Guidance Officer to collate relevant information for ASD to present to the treating paediatrician for diagnosis. This instrument was reviewed by Goldstein and Naglieri (2011) for effectiveness in identifying ASD in children between the ages of 2 and 18 according to the DSM-5, with the reliability and validity of the ASRS scores verified as accurately distinguishing ASD cases from other neuropsychological disorders and the general population. This test is administered to teachers and parents, providing a holistic perspective of the child’s symptoms.

Impact on the Individual and Interactions

The impact of ASD is dependent on the type and level of social, behavioural and cognitive dysfunction experienced by the child, their position on the autism spectrum. For children on the acute end of the spectrum, who may have severe cognitive impairment, there is a requirement for highly specialised fulltime care to assist them in everyday living. For the individual there will be a level of frustration resulting from their inability to be independent, a substantial emotional and economic burden on the family as carers and significant cost to the community in supporting the child physically and educationally (Lord et al., 2018). At the other end of the spectrum is the high functioning child with ASD who can learn the skills and rules of social interactions through interventions and observation of other children to participate competently and completely in all educational and social settings with minimal to no support. Along the continuum between these two extremes are most children with ASD who exhibit a range of behaviours that will impact on themselves and those around them. An ASD child may have difficulty coping with new and changing environments, such as school and childcare as it involves dealing with large numbers of adults and children who have patterns of behaviour with which they are not familiar and are highly variable. This experience can create anxiety, which may lead to an increase in self-stimulating, repetitive behaviours or they may act out with aggression, tantrums or withdraw (Smith & Iadarola, 2015). High levels of anxiety are common in the ASD child, however the rates of anxiety and depression in ASD teenagers increase significantly (Volkmar et al., 2014). Engagement in peer relationships can be hindered by the child’s social deficits, language delay and their own preference for solitude (Sharma et al., 2018). In the school setting, the child’s peers may find it difficult to relate to the child and be hesitant to engage due to the unpredictability of their behaviours. For the family there is significant stress associated with managing the child’s behaviours daily and securing the child’s future on a long-term basis. Identifying appropriate interventions that will help the child can create financial burden on the family (Smith & Iadarola, 2015).

Suggested Interventions

Research suggests early intervention for an ASD child provides the most successful outcomes, particularly for behavioural interventions (Volkmar et al., 2014). In the circumstance that a child is unable to engage due to maladaptive behaviours, it will be necessary to complete a Functional Behaviour Analysis (FBA) to identify triggers, the purpose of the behaviours and a plan to modify them to be more socially appropriate. Intervention for an ASD child will be multifaceted, dependent on the child’s identified strengths and vulnerabilities, which will be identified through the paediatric assessment and the ASRS. This will guide the involvement of external support agencies and inform the Individual Support Plan (ISP) developed in the school. The ISP provides school staff with information specific to the needs of the child and details the goals and strategies to support the child’s development, in the areas of verbal and non-verbal communication, social and motor skills, academic and behaviour capabilities (Volkmar et al., 2014). The plan is constructed with the parents and inclusive of external services working with the child to ensure there is consistency and compatibility for the child in the language, and strategies used by all adults. Establishing a productive relationship with the parents is crucial and aided through regular reviews of the ISP to ensure it is meeting the changing needs of the child.