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From the Emotional Integration to the Cognitive Construction: The Developmental Approach of Turtle Project in Children with Autism Spectrum Disorder

Authors:
  • Institute of Ortophonology
  • Instutute of Ortophonology
  • Institute of Ortophonology, Rome, Italy
  • Institute of Ortophonology

Abstract and Figures

Background: Children with autism spectrum disorder show a deficit in neurobiological processes. This deficit hinders the development of intentional behavior and appropriate problem-solving, leading the child to implement repetitive and stereotyped behaviors and to have difficulties in reciprocal interactions, empathy and in the development of a theory of mind. The objective of this research is to verify the effectiveness of a relationship-based approach on the positive evolution of autistic symptoms. Method: A sample of 80 children with autism spectrum disorder was monitored during the first four years of therapy, through a clinical diagnostic assessment at the time of intake and then in two follow-up. Results: The results showed that through the Autism Diagnostic Observation Schedule it is possible to assess the socio-relational key elements on which the therapy is based. There was evidence, in fact, of significant improvements after two and four years of therapy, both for children with severe autistic symptoms and for those in autistic spectrum. Conclusions: Socio-relational aspects represent the primary element on which work in therapy with autistic children and can be considered as indicators of a positive evolution and prognosis that will produce improvements even in the cognitive area.
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Volume 6 • Issue 1 • 1000160
Autism Open Access
ISSN:2165-7890 AUO, an open access journal
Open AccessResearch Article
Autism - Open Access
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ISSN: 2165-7890
Di Renzo et al., Autism Open Access 2016, 6:1
http://dx.doi.org/10.4172/2165-7890.1000160
Keywords: Autism; Autism spectrum; ADOS; erapeutic ecacy;
Developmental approach
Introduction
In DSM-5 (APA, 2013), autism is within the Neurodevelopmental
disorders, a diagnostic category that includes conditions with onset
in the early stages of development, characterized by developmental
decits with impairment in the personal, social and educational areas.
e autism spectrum disorder is dened as a decit in the socio-
emotional reciprocity, with reduced sharing of interests, emotions
or feelings and decient use of communicative behaviors, verbal or
otherwise that are poorly integrated between them. ese decits in
the quality of social interaction include abnormal eye contact and body
language to regulate and modulate the relationship with the other,
decits in understanding and use of gestures, in facial expression and
in the presence and sharing of symbolic play. e severity of symptoms
is based on both the impairment of social communication and patterns
of restricted and repetitive behaviors. ese behaviors are the result of a
defensive, archaic process, the adhesive identication, which eliminates
the distinction between the child and the external object and concerns
the outward sensoriality, as linked to sensory pathways, rather than
the understanding of the functions and states of mind [1]. Another
archaic defensive mechanism, the dismantling, implies a splitting
process by which the autistic child reduces the object to a multiplicity
of monosensory, indistinguishable events. e object is disassembled
in small simplied portions according to segments of the sensory
experience, rather than split along lines of emotional experience. Such
archaic processes prevents the functional and symbolic use of objects,
and the attraction for the perceptual monosensory quality prevents
thinking skills [1-7].
e feelings and emotions must ow in an organized and integrated
way, so if the informations are not organized or arrive “disassembled”
to the child, it will be dicult to give meaning to the emotional and
physical experience as well as being able to give an adaptive and
intentional response for a communicative purpose or intention [8].
ese characteristic aspects of autism suggest the diculty of the
diagnostic assessment, both for the sensory component, which prevents
or greatly restricts the use of diagnostic tools, both for the heterogeneity
in the socio-cognitive functioning that we can nd in autism, basing
on the symptomatic severity and intensity of stereotyped behaviors
and sensory research. e Psychodynamic Diagnostic Manual points
out the decit in those emotional process that leads to empathy and
refers to the aective diathesis, a theoretical concept also underlying
the DIR-Floortime approach (Developmental Individual-Dierence
Relationship-based model), so that in autism spectrum disorders
there would be a decit in the neurobiological processes that allow
the creation of appropriate connections between emotions, sensory
processing, motor planning and the formation of symbols [9]. ese
deciencies hinder the development of an intentional behavior and
an appropriate problem-solving leading the child to implement
repetitive and stereotyped behavior and to have diculty in reciprocal
interactions, empathy, and in the development of a theory of mind
[10,11]. e Institute of Ortofonologia, in line with this model, bases
its diagnostic and therapeutic process on a developmental approach,
*Corresponding author: Di Renzo M, Istituto di Ortofonologia (IdO), Rome, Italy,
Tel: 393355230562; E-mail: m.direnzo@ortofonologia.it
Received December 13, 2015; Accepted January 21, 2016; Published January
28, 2016
Citation: Di Renzo M, Bianchi di Castelbianco F, Vanadia E, Petrillo M, Racinaro
L, et al. (2016) From the Emotional Integration to the Cognitive Construction:
The Developmental Approach of Turtle Project in Children with Autism Spectrum
Disorder. Autism Open Access 6: 160. doi:10.4172/2165-7890.1000160
Copyright: © 2016 Di Renzo M, et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
From the Emotional Integration to the Cognitive Construction: The
Developmental Approach of Turtle Project in Children with Autism
Spectrum Disorder
Magda Di Renzo*, Federico Bianchi di Castelbianco, Elena Vanadia, Massimiliano Petrillo, Lidia Racinaro and Monica Rea
Istituto di Ortofonologia (IdO), Rome, Italy
Abstract
Background: Children with autism spectrum disorder show a decit in neurobiological processes. This decit
hinders the development of intentional behavior and appropriate problem-solving, leading the child to implement
repetitive and stereotyped behaviors and to have difculties in reciprocal interactions, empathy and in the
development of a theory of mind. The objective of this research is to verify the effectiveness of a relationship-based
approach on the positive evolution of autistic symptoms.
Method: A sample of 80 children with autism spectrum disorder was monitored during the rst four years of
therapy, through a clinical diagnostic assessment at the time of intake and then in two follow-up.
Results: The results showed that through the Autism Diagnostic Observation Schedule it is possible to
assess the socio-relational key elements on which the therapy is based. There was evidence, in fact, of signicant
improvements after two and four years of therapy, both for children with severe autistic symptoms and for those in
autistic spectrum.
Conclusions: Socio-relational aspects represent the primary element on which work in therapy with autistic
children and can be considered as indicators of a positive evolution and prognosis that will produce improvements
even in the cognitive area.
Citation: Di Renzo M, Bianchi di Castelbianco F, Vanadia E, Petrillo M, Racinaro L, et al. (2016) From the Emotional Integration to the Cognitive
Construction: The Developmental Approach of Turtle Project in Children with Autism Spectrum Disorder. Autism Open Access 6: 160.
doi:10.4172/2165-7890.1000160
Page 2 of 9
Volume 6 • Issue 1 • 1000160
Autism Open Access
ISSN:2165-7890 AUO, an open access journal
centered on the relationship, which considers as integrated the cognitive
and aective components [7,11-25].
We believe that during development the language, intelligence
and socio-emotional skills are acquired through relationships and
interactions that involve aective exchanges. In the last 40 years the
clinical work of the Institute of Ortofonologia gave rise to a specic
program for autism called the Turtle Project, which provides a
diagnostic and therapeutic plan based on the emotional, relational
and cognitive potentialities of the child [24-28]. e project includes
activities mediated by the body, as it is an important vehicle of emotions,
and is centered on relational aspects, to strengthen those processes
maybe lacking in the early stages of development [24,25,29-34].
Even the current theories of intersubjectivity and attachment and the
researches about insightfulness show how the attunement of caregivers
on child’s emotional states can promote openness to relationship and
communication [25,35-39].
In the context of current research on autism, the Autism Diagnostic
Observation Schedule (ADOS) is recognized as a tool of choice in
the evaluation and quantication of the severity of symptoms [40].
In this study we adopted the rst edition of the ADOS because at
the beginning of our research the ADOS-2 was not yet available. e
ADOS is recommended in several Best Practice Guidelines (California
Department of Developmental Services, 2002; National Research
Council, 2001) as an appropriate standardized diagnostic observation
tool [41-43].
Several studies have used the ADOS in correlations with other
observation tools such as questionnaires and/or interviews for parents
and other scales of direct observation of the behaviors attributed to
an autism spectrum disorder [44-48]. ese researches focused on
the utility and validations of the diagnosis of autism according to
the instruments used, but have not considered the ADOS to evaluate
through the re-tests the longitudinal evolution of symptoms during
the years of treatment. In this study, in addition to the assessment of
the cognitive skills, it will be taken into consideration all the social and
communicative target behaviors according to the areas of the ADOS
assessment, in order to evaluate over time not only the changes of the
global score but also the evolution of each individual communicative
and relational behavior, the evolution of the severity of restricted
and repetitive behaviors (mannerisms, unusual sensory interests and
stereotyped behaviors and interests) and the ability to use objects
(stereotyped/sensorial, functional and symbolic).
e therapeutic project here described and used is based on a
clinical, developmental approach that treats as crucial the motivation
in learning processes. Considering as inseparable the aective and
cognitive components and also, in developmental terms, the priority
of the emotional regulation, the therapy aims to activate the emotional
relationship with the child to help him in the construction of cognitive
schemas.
We have already seen that in autistic children the primary decit
is at an emotional level even before cognitive and that the block in
the emotional development lies in a very early stage, in the psycho-
physical area [16,17,24,25,29,32,33,49,50]. e results showed some
socio-cognitive improvements and the eectiveness of a developmental
approach based on the relationships and focused on aective and bodily
processes, on defensive archaic process and on sensory integration,
that is on the emotional blocks preceding cognitive processes which
are functional to the expression of the intellectual potential of autistic
children [18,22,23,49,50-53]. ese results highlight the importance of
the emotional dimension in the structuring of the autistic symptoms,
showing that the information processing in interactive contexts includes
intentional and emotional aspects that organize and enhance the
activity and cognitive skills, in response to previous perspectives that
have shied the focus mainly on the cognitive determinants [50,54-56].
e main objective of this research is to examine the therapeutic
ecacy of the Turtle Project on the evolution of behavioral and
relational symptoms of autistic children monitored for a period of four
years. e specic objectives are: to determine the dierences in the
cognitive and symptomatic prole of children with autism and children
with spectrum, and verify their evolution over time; investigate the
relationship between the cognitive and behavioral aspects before and
aer treatment; dene, within the diagnostic assessment in parallel with
the ADOS, the key elements on which to set the therapy, in order to
consider them as indicators of a future aective, cognitive symptomatic
change both in children with autism and in those with spectrum.
Materials and Method
Participants
e sample was composed of 80 children (64 males and 16 females)
between 24 and 131 months, with an autism spectrum disorder
diagnosis. Most of children came from middleclass families. At intake
(T1), 64 children (82.8% males; mean chronological age: 54.45 months;
SD=24.9) have been diagnosed with autism (AUT), and 16 (68.8%
males; mean chronological age: 60.56 months; SD=26.0) have been
diagnosed with autism spectrum disorder (SpD) (Table 1). Aer two
(T2) and four (T3) years of treatment all children were reassessed
with the same diagnostic protocol performed at T1. Informed consent
was obtained from all parents (Declaration of Helsinki) and the study
complied with the national ethical guidelines and APA criteria.
Procedure
Participants were recruited from the e Institute of Ortofonologia.
e Institute works in agreement with the National Health System and
follows the procedures for taking charge of children and their families
according to the treatment plan established by the Regional Health Agency.
Autism Spectrum Disorder
(N=64) (N=16)
Variable
Male % 82.8 68.8
Italian % 87.5 93.8
SES
Low 4.7 /
Medium 75 87.5
High 20.3 12.5
Age in months, mean (SD) 54.45 (24.9) 60.56 (26.0)
IQ scores 56.31 (16.5) 77.69 (19.6)
ADOS score 17.67 (2.9) 9.44 (1.4)
A - Communication 6.25 (1.1) 3.88 (0.8)
B - Social Interaction 11.38 (2.3) 5.56 (1.2)
C - Play 1.77 (0.5) 0.63 (0.6)
D - Repetitive behaviours 4.88 (1.5) 1.94 (1.1)
D1 – Unusual sensory interest in play 1.61 (0.5) 0.56 (0.5)
D2 – Hand, nger, and other mannerisms 1.59 (0.7) 0.69 (0.7)
D4 – Unusually repetitive interests 1.67 (0.5) 0.69 (0.5)
Table 1: Descriptive Characteristics: 80 Children with Autism and Spectrum
Disorder at Intake.
Citation: Di Renzo M, Bianchi di Castelbianco F, Vanadia E, Petrillo M, Racinaro L, et al. (2016) From the Emotional Integration to the Cognitive
Construction: The Developmental Approach of Turtle Project in Children with Autism Spectrum Disorder. Autism Open Access 6: 160.
doi:10.4172/2165-7890.1000160
Page 3 of 9
Volume 6 • Issue 1 • 1000160
Autism Open Access
ISSN:2165-7890 AUO, an open access journal
e children were enrolled in this research between 2009 and
2011. e clinical diagnosis was made by a team of highly qualied
clinicians (5 to 10 years of experience in the eld of autism) formed
by psychologists/psychotherapist, neurologists, psychiatrist, speech
therapists and occupational therapists. e diagnosis of autism was
based on the DSM-IV criteria (APA, 1994), hence, in addition to
clinical observations, the children were administered the Autism
Diagnostic Observation Schedule [40]. e experts, who carried out
the assessment of the child and administered the ADOS, are not the
same as those involved in the child’s therapy. is research meets the
ethical guidelines and legal requirements of the country in which was
conducted. Aer receiving the diagnosis, all children were included in
the Turtle Project (TP), described below.
Turtle project1
e Turtle Project includes a total of 10 hours a week of rehabilitation,
of which 3 hours of outpatient activities, 4 hours of home care divided
into two weekly sessions of 2 hours each one, 3 hours a week of aquatic
and animal-assisted therapy. Besides the 10 hours described, there are
individual and group counselling for parents, educational support in
schools, specialist visits, diagnostic periodic observations, physiatrist
rehabilitation and neuropsychological assessments also inherent
cognitive and social skills. Outpatient treatment includes individual
and group sessions, speech therapy, music therapy, psychomotor skills,
psychotherapy and a pedagogical work specically directed to cognitive
diculties.
e common goal of the various approaches to treatment was to
emphasize the emotional and relational dimension so to enrich the
repertoire of communicative behaviors, allowing the expression of
latent intellectual and social abilities. e project involves a strong
1The name of Turtle Project comes from wanting to communicate to parents that
often the therapeutic process can be long and challenging.
partnership between all therapists, guaranteed by the presence of
coordinators that promote an integrated communication between
operators, school and family. e following are treatment options that
can be modied basing on the age and symptomatic impairment of
each child, according to decit or potential areas found in the child’s
cognitive and social functioning (Table 2).
Measures
Autism diagnostic observation schedule-ADOS
e Autism Diagnostic Observation Schedule – ADOS [40]
is a semi-structured assessment of child’s social interaction,
communication, play and creativity, and repetitive or restricted
behaviors or interests. Activities in each module vary from those
appropriate for non-verbal children to those appropriate for verbally
uent children, adolescents, and adults. ADOS is one of the most
widely used observation instruments for the assessment of autism and
it is recommended in several Best Practice Guidelines as an appropriate
standardized diagnostic observation tool (California Department of
Developmental Services, 2002; National Research Council, 2001).
e ADOS classications are based on specic coded behaviors
that are included in a scoring algorithm using the DSM-IV diagnostic
criteria, resulting in a Communication score, a Reciprocal Social
Interaction score, and a Total score (a sum of the Communication
and Reciprocal Social Interactions scores). e total score enables the
classication of three diagnostic categories: Absence of autism (ADOS
score between 0 and 6); Autistic spectrum (ADOS score between 7
and 11); and Autism (ADOS score between 12 and 24). e minimum
Communication score for autism is four, and the minimum score for
the spectrum is two; the minimum Reciprocal Social Interaction score
for autism is seven, and the minimum for the spectrum is four. A child
meets criteria for a classication of autism if the scores in the Social
Activities for children of all ages Description of activities
Home therapy (twice a week: 2+2 hours)
Home therapy includes a range of therapeutic activities which vary according to the age of the child, in order
to expand the communication and the ability of the child's relationship with the members of his family. The
goal of this therapy is to help the family in reading child’s behaviours, even the most enigmatic, and to share
the understanding of his emotional states [2,5,7,16,17,26,27,39,56,57].
External activities (Aquatic and Pet therapy: 1½+1½ hours) The aquatic environment and contact with animals, both provided once a week, are designed to improve
child’s attunement with the outside world [58-61].
Activities in our Clinical Center for children from 2.5 to 5 years old (3 total hours per week)
Body mediated therapy (1½ hours):
• psychomotor activities
• mother-child therapy
• psychological support
These treatments offer the possibility of an individual, dyadic or group work depending on the specic
characteristics of each child, to provide a context in which the child can make his emotional experiences
in a creative and shareable way [26-28] . The main work is on the integration of unisensory perceptions so
that the various segments of sensory experiences can gradually evolve into a rst emotional experience
[8,29,32,33] with mirroring and recognizable meanings [1-4,6,8,39].
Music therapy (1½ hours)
This therapy uses the sound, rhythm and musicality to integrate, coordinate and unify isolated perceptions
in one recognizable experience. The goal is to allow the child to bond with his perceptions [62] in order to
coordinate experience of a complete, emotionally connoted object (for example, the differentiation between
common sound and the recorded maternal voice).
Activities in our Clinical Center for children over 5 years of age (3 total hours per week)
Speech therapy, in group or individual (1½ hours)
This therapy promotes the communicative, intentional and reciprocal language. Initially the therapy is
focused on the development of the pre-requisites of communication, and then it works on the phono-
articulatory and pragmatic aspects of the communication [63,64].
Neurocognitive rehabilitation (1½ hours) This therapy promotes cognitive processes such as attention, visual memory, abstraction and visual-
perceptual skills so to harmonize and integrate in a more functional way the cognitive prole of the child.
Activities that do not require the presence of the child (in addition to the 10 hours per week)
School support
This includes classroom observation and meetings with teachers, to identify social and academic objectives
and to ensure a better understanding of the disorder, to promote the inclusion into the class [65,66]. In Italy,
children with disabilities are placed in regular classes, where there is a special education teacher.
Meetings with parents
These include activities such as informative sessions about the disorder of the child, individual or group
counselling and psychological therapy. The formative experiences in the group also include activities that
promote non-verbal communication and body contact, such as psychodrama or role-playing games [67,68].
Table 2: Turtle Project: 10 hours a week of therapy, according to the age of the children.
Citation: Di Renzo M, Bianchi di Castelbianco F, Vanadia E, Petrillo M, Racinaro L, et al. (2016) From the Emotional Integration to the Cognitive
Construction: The Developmental Approach of Turtle Project in Children with Autism Spectrum Disorder. Autism Open Access 6: 160.
doi:10.4172/2165-7890.1000160
Page 4 of 9
Volume 6 • Issue 1 • 1000160
Autism Open Access
ISSN:2165-7890 AUO, an open access journal
and Communication domains and the total on the algorithm meet or
exceed cut-o scores.
Communication Scale includes ve items that contribute to the
overall communication score: Frequency of vocalization to others,
Stereotyped/idiosyncratic words, Use of other’s body to communicate,
Pointing, Gestures.
Social Reciprocal Interaction Scale includes seven items that
contribute to the overall Socialization score: Eye contact, Facial
expressions, Shared enjoyment, Showing, Initiation of joint attention,
Response to joint attention, and Quality of social overtures.
Items regarding play and stereotyped behaviors are also coded but
are not included in the diagnostic algorithm.
Play behaviors includes 3 items: Symbolic play, Functional play and
stereotyped play.
Stereotyped behaviors include 3 items: Unusual sensory interests,
Hand and nger mannerisms and Repetitive interests.
Play scores are coded using a 0 to 2 point: 0 indicates symbolic play;
1 indicates functional play and 2 indicates stereotyped play.
All behaviors are coded using a 0 to 3 point coding system: 0
indicating a normal behavior, 1 indicating a mild abnormal behavior, 2
indicating denitive abnormality, and 3 indicating severe abnormality
that interferes with the child’s functioning.
Cognitive assessment
The Leiter International Performance Scale–Revised (Leiter–R)
[69] is a non-verbal measure of the global intellectual function of
children and adolescents aged between 2 and 20 years. Neither the
examiner nor the child is required to speak, and the child doesn’t
need to read or write, either. General intelligence and discrete ability
areas were measured with 20 subtests and numerous composites.
Scores were provided for each subtest and skill area, plus a full IQ
scale score indicating non-verbal global intellectual functioning.
The full IQ score had a mean of 100 and a standard deviation of 15.
The intellectual disability was indicated by a composite score that is
two standard deviations or more below the mean, so a score of 70
was the borderline value.
Statistical method
ANOVA was used to evaluate the dierences between groups.
Repeated measures ANOVA was used to analyze the changes in the
abilities aer two and four years from the beginning of treatment. Eect
sizes were calculated using partial eta-squared (η2
p). A η2
p of 0.02 was
considered a small eect size, 0.13 a medium eect size and 0.23 a large
eect size [70]. e signicance level was set at p<0.05. Chi-squared
analyses were conducted to examine group dierences in demographic
variables between the categorical variables. All statistical analyses were
performed using SPSS Soware Version 19.0.
Results
e descriptive of the sample at T1
At T1, both the AUT and SpD groups were comparable for
chronological age (F1,79=0.75; p=0.38), for gender (Chi-square=1.58;
p=0.21), for nationality (Chi-square=2.93; p=0.57) and for SES (Chi-
square=1.42; p=0.49); however, the AUT group showed signicantly
lower scores than the SpD group in cognitive functioning (IQ; F1,
79=19.87; p<0.01; η2
p=0.20) and higher scores in all the subscales of
ADOS (Wilks’ lambda: 0.36; p<0.001, η2
p=0.20; Communication: F1,
79=65.67; p<0.01; η2
p=0.46; Social Interaction: F1, 79=95.57; p<0.01;
η2
p=0.55; Play: F1, 79=67.53; p<0.01; η2
p=0.46; Repetitive behaviors: F1,
79=51.30; p<0.01; η2
p=0.40). ere were no signicantly dierences for
chronological age on ADOS scores (F1, 79=1.48; p=0.23), nor on IQ
scores (F1, 79=3.70; p=0.07).
Differences between children with autism and autism spectrum
after treatment
Cognitive abilities: Aer 2 years of treatment (T2), AUT children
and SpD children showed a signicant increase in IQ scores and this
increase signicantly continues even aer 4 years (T3) (repeated eect:
F2, 78=32.06, p<0.001, η2=0.29; eect groups: F2, 78=17.80; p<0.001,
η2
p=0.19; repeated eect x groups: F2, 78=0.01; p=0.98) (Table 3).
Diagnostic categories: At T2 the number of AUT children
signicantly decreased: 19 children of 80 were no longer included in
the autism category (Chi square=28.02; p<0.001). At T3 the number
of AUT children continued to decrease (Chi square=58.74; p<0.001):
31 of 80 children (38.7%) didn’t receive a diagnosis of autism. Of these
31 children, 13 (81.25%) came from the SpD group at the intake and 18
children (28.12%) came from the AUT group at the intake.
Moreover, at T3 17 children fell into the SpD category: of these
children, 3 (18.7%) came from the SpD group at the intake and 14
(21.9%) came from the AUT group at the intake. Finally, 32 children
fell into the AUT group, and all came from the AUT group at the intake.
With respect to the chronological age variable, there were no
signicant dierences between groups (Wilk’s Lambda=0.98, p=0.48).
e analysis of variance for repeated measures showed a signicant
reduction in ADOS scores at T2 and T3 for children in AUT group and
for those in SpD group (repeated Eect: F2, 78=65.15; p<0.001, η2=0.45;
eect groups: F2, 78=59.66; p<0.001, η2
p=0.43; eect repeated x groups:
F2, 78=0.68; p=0.50) (Table 3 ).
e data analysis revealed the same trend of score reduction of
the symptomatology in all functional areas, measured by the ADOS
subscales; although the dierence between the AUT and SpD groups
T1 T2 T3
AUT SpD AUT SpD AUT SpD
IQ scores 56.31 (16.5) 77.69 (19.6) 67.25 (20.5) 89.31 (19.1) 72.59 (23.8) 94.12 (20.1)
ADOS score 17.67 (2.9) 9.44 (1.4) 13.20 (4.7) 6.00 (3.1) 10.9 (5.1) 3.90 (3.8)
A - Communication 6.25 (1.1) 3.88 (0.8) 4.84 (1.7) 2.31 (1.4) 3.92 (1.9) 1.44 (1.3)
B - Social Interaction 11.38 (2.3) 5.56 (1.2) 8.34 (3.2) 3.69 (2.1) 7.02 (3.5) 2.44 (2.5)
C - Play 1.77 (0.5) 0.63 (0.6) 0.92 (0.7) 0.19 (0.4) 0.66 (0.7) 0.13 (0.3)
D - Repetitive Behaviors 4.88 (1.5) 1.94 (1.1) 3.39 (1.9) 0.69 (1.1) 2.95 (2.0) 0.69 (1.5)
Table 3: Means (SD) for the IQ and ADOS--Module 1, at Intake and after two and four years of treatment.
Citation: Di Renzo M, Bianchi di Castelbianco F, Vanadia E, Petrillo M, Racinaro L, et al. (2016) From the Emotional Integration to the Cognitive
Construction: The Developmental Approach of Turtle Project in Children with Autism Spectrum Disorder. Autism Open Access 6: 160.
doi:10.4172/2165-7890.1000160
Page 5 of 9
Volume 6 • Issue 1 • 1000160
Autism Open Access
ISSN:2165-7890 AUO, an open access journal
remained constant over time, at T3 all children show signicant
improvements in communication scores, in social reciprocal interaction
scores, in play scores, in repetitive and restricted behaviors scores.
Communication Scale: Analysis of multivariate variance
(MANOVA) revealed a signicant dierences between groups in
communicative behaviors, at T1 (Wilks’ lambda: 0.43; p<0.001,
η2
p=0.56). As shown in Figure 1A, the AUT group had more decits
than the SpD group in frequency of the vocalizations directed to others
(F1, 78=32.00; p<0.001, η2
p=0.29), in the use of pointing (F1, 78=57.98;
p<0.001, η2
p=0.43) and in the use of communicative gesture (F1,
78=21.30; p<0.001, η2
p=0.21). ere was no dierence between groups
on stereotyped/idiosyncratic words (F1, 78=12.00; p=0.73), because
the language is almost entirely absent in these children. ere were
no dierences between group in the use of other’s body (F1, 78=1.36;
p=0.25). ere were no signicantly eect for chronological age (Wilk’s
Lambda=0.98; p=0.78).
Treatment x group repeated measures analysis (Table 4) conrmed
that frequency of vocalizations directed to others, frequency of pointing
and of gestures were the communication items that dierentiated
between the groups over time. ese pathological behaviors improve
over time in both groups, although they remain present signicantly
higher frequency in the AUT group if compared to the SpD group.
Stereotyped/idiosyncratic words increased in AUT group and
disappeared in the SpD group. e use of other’s body to communicate
was similar between the two groups and decreased signicantly over
time in both groups.
Social Reciprocal Interaction Scale: the MANOVA analysis revealed
a signicant dierence between groups in social reciprocal interaction
scale, at T1 (Wilks’ lambda: 0.33; p<0.0001, η2
p=0.67). As shown in
Figure 1B, the AUT group had signicantly more higher scores than the
SpD group in all Socialization items: Eye contact (F1, 78=50.14; p<0.001,
η2
p=0.39), Facial expressions (F1, 78=29.56; p<0.001, η2
p=0.27), Shared
enjoyment (F1, 78=59.49; p<0.001, η2
p=0.43), Showing (F1, 78=88.30;
p<0.001, η2
p=0.53), Initiation of joint attention (F1, 78=26.03; p<0.001,
η2=0.25), Response to joint attention (F1, 78=21.62; p<0.001, η2
p=0.22)
and Quality of social overtures (F1, 78=50.96; p<0.001, η2
p=0.39).
A series of group x time ANOVA repeated measures (Table 5)
conrmed that all socialization items remained dierent between the
groups over time; in particular, the dysfunctional eye contact, the
initiation of joint attention, the response to joint attention and the
quality of social overtures, signicantly decreased over time in both
groups, although the scores were higher in the AUT group than in the
SpD group.
In addition, AUT children showed signicant improvements over
time in facial expressions and in showing (T1, T2 and T3); instead, SpD
children improved these behaviors only between T1 and T2. Finally,
while in the AUT group the improvement on shared enjoyment was
evident (T1, T2 and T3), in the SpD group no improvement of shared
enjoyment scores was observed over time, because they already started
from a score close to 0 (indicating absence of pathological behavior).
ere were no signicantly eect for chronological age (Wilk’s
Lambda=0.98; p=0.53).
Stereotyped behaviors: a mixed factorial MANOVA was conducted
to verify dierences between groups on stereotyped behaviors and
to analyze the changes over time. e results showed that the AUT
children showed more stereotyped behaviors than the SpD children, at
the intake (Wilks’ lambda: 0:18; p<0.001, η2
p=0.81) aer two years of
treatment (Wilks ‘lambda: 0.70; p<0.001, η2
p=0.29) and aer four years of
0
1
2
A2 Frequency of
communication
A5 Stereotyped
use of words
A6 Use of other’s
body
A7 Pointing A8 Gesture
AUT
SpD
Figure 1A: Differences between groups in Communication items.
0
1
2
Unusual eye
contact
Facial
expressions
directed to
others
Shared
enjoyment in
interaction
Showing Spontaneous
initiation of
joint
attention
Response to
joint
attention
Quality of
social
overtures
AUT
SpD
Figure 1B: Differences between groups in Social Reciprocal Interaction Scale. Legend: AUT = children with autism; SpD = children with spectrum disorder.
Citation: Di Renzo M, Bianchi di Castelbianco F, Vanadia E, Petrillo M, Racinaro L, et al. (2016) From the Emotional Integration to the Cognitive
Construction: The Developmental Approach of Turtle Project in Children with Autism Spectrum Disorder. Autism Open Access 6: 160.
doi:10.4172/2165-7890.1000160
Page 6 of 9
Volume 6 • Issue 1 • 1000160
Autism Open Access
ISSN:2165-7890 AUO, an open access journal
effect, p (η2
p)
Socialization items Group T1 T2 T3 Group Time Group x time
B1 – Eye contact AUT 1.73 (0.45) 1.13 (0.63) 0.91 (0.66) 0.001 (0.33) 0.001 (0.31) 0.23
SpD 0.81 (0.54) 0.50 (0.52) 0.19 (0.40)
B3 – Facial expressions AUT 1.50 (0.50) 1.20 (0.62) 0.91 (0.71) 0.001 (0.31) 0.001 (0.21) 0.81
SpD 0.75 (0.45) 0.38 (0.50) 0.19 (0.40)
B5 – Shared enjoyment AUT 1.41 (0.55) 0.86 (0.69) 0.61 (0.66) 0.001 (0.34) 0.01 (0.16) 0.01 (0.07)
SpD 0.25 (0.45) 0.13 (0.34) 0.06 (0.25)
B9 – Showing AUT 1.87 (0.33) 1.28 (0.86) 0.98 (0.92) 0.001 (0.31) 0.001 (0.32) 0.95
SpD 0.94 (0.44) 0.38 (0.62) 0.06 (0.25)
B10 – Initiation of joint attention AUT 1.64 (0.54) 1.03 (0.69) 0.80 (0.74) 0.001 (0.23) 0.001 (0.24) 0.56
SpD 0.87 (0.50) 0.44 (0.51) 0.25 (0.58)
B11 – Response to joint attention AUT 1.28 (0.65) 0.63 (0.68) 0.39 (0.60) 0.05 (0.06) 0.001 (0.22) 0.05 (0.04)
SpD 0.44 (0.63) 0.06 (0.65) 0.06 (0.25)
B12 – Quality of social overtures AUT 1.91 (0.29) 1.72 (0.45) 1.58 (0.53) 0.001 (0.49) 0.001 (0.18) 0.31
SpD 1.25 (0.44) 0.94 (0.44) 0.69 (0.60)
Table 5: Means (SD) for the social reciprocal interaction scale, at intake and over time.
effect, p (η2
p)
Stereotyped Behaviours Group T1 T2 T3 group time group x time
D1 – Unusual sensory interests AUT 1.61 (0.58) 1.05 (0.78) 0.92 (0.78) 0.001 (0.30) 0.001 (0.18) 0.06
SpD 0.56 (0.51) 0.06 (0.25) 0.31 (0.60)
D2 – Hand and nger mannerisms AUT 1.59 (0.68) 1.08 (0.78) 1.06 (0.85) 0.001 (0.26) 0.001 (0.16) 0.93
SpD 0.69 (0.70) 0.25 (0.58) 0.19 (0.40)
D4 – Repetitive interests AUT 1.67 (0.53) 1.27 (0.67) 0.97 (0.69) 0.001 (0.35) 0.001 (0.21) 0.55
SpD 0.69 (0.48) 0.38 (0.62) 0.19 (0.54)
Table 6: Means (SD) for the stereotyped behaviours, at intake and over time.
treatment (Wilks’ lambda: 0.76; p<0.001, η2
p=0.24) (Table 6). ere were
no signicant eect for chronological age (Wilk’s Lambda=0.98, p=0.46).
Play behaviors: As shown in Figure 2A, a stereotyped play was
present in the 78.1% of AUT children at T1, and in 6.3% of SpD
children. Aer two years of treatment, there was a signicant reduction
of the number of AUT children with stereotyped play (Chi square=5.01;
p<0.05). Aer four years of treatment, the frequency of stereotyped play
in AUT children remained stable.
effect, p (η2
p)
Socialization items Group T1 T2 T3 group time group x time
B1 – Eye contact AUT 1.73 (0.45) 1.13 (0.63) 0.91 (0.66) 0.001 (0.33) 0.001 (0.31) 0.23
SpD 0.81 (0.54) 0.50 (0.52) 0.19 (0.40)
B3 – Facial expressions AUT 1.50 (0.50) 1.20 (0.62) 0.91 (0.71) 0.001 (0.31) 0.001 (0.21) 0.81
SpD 0.75 (0.45) 0.38 (0.50) 0.19 (0.40)
B5 – Shared enjoyment AUT 1.41 (0.55) 0.86 (0.69) 0.61 (0.66) 0.001 (0.34) 0.01 (0.16) 0.01 (0.07)
SpD 0.25 (0.45) 0.13 (0.34) 0.06 (0.25)
B9 – Showing AUT 1.87 (0.33) 1.28 (0.86) 0.98 (0.92) 0.001 (0.31) 0.001 (0.32) 0.95
SpD 0.94 (0.44) 0.38 (0.62) 0.06 (0.25)
B10 – Initiation of joint attention AUT 1.64 (0.54) 1.03 (0.69) 0.80 (0.74) 0.001 (0.23) 0.001 (0.24) 0.56
SpD 0.87 (0.50) 0.44 (0.51) 0.25 (0.58)
B11 – Response to joint attention AUT 1.28 (0.65) 0.63 (0.68) 0.39 (0.60) 0.05 (0.06) 0.001 (0.22) 0.05 (0.04)
SpD 0.44 (0.63) 00.06 (0.65) 0.06 (0.25)
B12 – Quality of social overtures AUT 1.91 (0.29) 1.72 (0.45) 1.58 (0.53) 0.001 (0.49) 0.001 (0.18) 0.31
SpD 1.25 (0.44) 0.94 (0.44). 0.69 (0.60)
Table 4: Mean (SD) differences between groups on communication scale, at intake and over time.
e frequency of functional play in AUT children increased
signicantly between T1 and T2 (Chi square=5.24; p<0.05), while in the
SpD group decreased (Figure 2B) because in the meantime symbolic
play was appeared (Figure 2C).
At T1 symbolic play was absent in almost all the AUT children (it
was present only in a child of 36 months, who aer two years received
a diagnosis of no AUT), at T2 it appeared in a number of children not
still signicantly relevant (Chi square=2.40; p=0.12), but increased
Citation: Di Renzo M, Bianchi di Castelbianco F, Vanadia E, Petrillo M, Racinaro L, et al. (2016) From the Emotional Integration to the Cognitive
Construction: The Developmental Approach of Turtle Project in Children with Autism Spectrum Disorder. Autism Open Access 6: 160.
doi:10.4172/2165-7890.1000160
Page 7 of 9
Volume 6 • Issue 1 • 1000160
Autism Open Access
ISSN:2165-7890 AUO, an open access journal
Ster eotype d Play
0
20
40
60
80
100
T1 T2 T3
% of play behaviou rs
AUT
SpD
Functional Play
0
20
40
60
80
100
T1 T2 T3
% of play behaviours
AUT
SpD
Symbo lic Play
0
20
40
60
80
100
T1 T2 T3
% of play behaviou rs
AUT
SpD
A
B
C
Figure 2: Percentage of Play Behaviours in AUT and SpD groups, over time.
Legend: T1= At Intake; T2= After 2 years of treatment; T3= After 4 years of
treatment; AUT = children with autism; SpD = children with spectrum disorder.
signicantly at T3 (Chi square=7.22; p<0.01). In SpD group, the
frequency of children with symbolic play increased signicantly from
T1 to T2 (Chi square=4.70; p<0.05), and then it remained stable at T3
(Chi square=1.10; p=0.29).
Discussion
The reduction in the number of autism diagnoses based on the
ADOS scores, after two and four years of treatment, the significant
reduction of symptoms in all the areas assessed (language and
communication, reciprocal social interaction, play and restricted
and repetitive behaviors) and the progressive improvements in IQ
in the entire sample of the study, demonstrate the effectiveness of
a developmental approach based on the relationship, centered on
affective aspects, on defensive archaic processes and on sensory
integration [16-23,49].
e initial assessment of children in the sample showed the
signicant dierences between the ADOS diagnosis of autism and
autism spectrum, based on the score obtained, regardless of the age of
the children. Moreover, lower scores in all areas of ADOS are indicative
of less structured autistic defences in children diagnosed SpD,
allowing a better quality of social and relational skills, as well as the
expression of the intellectual potential. e positive evolution of autistic
symptoms and the increasing percentage of children who fell into the
category of ADOS no-autism are detectable in children diagnosed SpD
already aer two years of therapy, highlighting the importance of the
distinction between the two categories of ADOS classication. e
children diagnosed SpD showed socio-relational and cognitive patterns
characterized by diculties in regulation, exibility and integration of
hypo-expressed skills, while children diagnosed AUT showed the total
absence of the same abilities.
At the initial assessment, the AUT group does not dier from the
SpD group only in the use of idiosyncratic/stereotyped words and use
of the other’s body. e use of the body of the other is the expression
of a defensive adhesiveness, in which the dierentiation and the limits
of the ego lose the boundaries in a contiguity where the body of the
other is used only for instrumental purposes and not for emotional
sharing [1,4,5,8,29,32,33,71]. is specic and precocious use of the
body as a form of communication and demand represents the closure
to other distal communication strategies, such as the pointing, the use
of gestures and vocal productions directed to another, but a therapeutic
work on body mediation and sensory integration can leads to open
to verbal and nonverbal forms of communication. Compared to the
presence of echolalia and idiosyncratic/stereotyped words, the low
score observed in both groups cannot be interpreted as proper use of
words, since it is an item that can be evaluated only if verbalizations
are present, while the entire sample of this research, at the time of
intake, was characterized by a general absence of language. e latest
version of the ADOS, the ADOS-2 includes this target item in the area
of restricted and repetitive behaviors, emphasizing the stereotyped and
sensory aspect of this way of using vocalizations and verbalizations, not
considering it as a reliable element of evaluation in the language and
communication area [72].
e area of reciprocal social interaction is dierent between the
two groups in all target behaviors of the ADOS evaluation in the whole
therapy period and in a more signicant way than the Language and
Communication area. Especially the shared enjoyment during the
interaction, intended as the ability to show pleasure during activities
with the other, distinguishes the AUT group from the SpD group that
already shows this capacity at the time of taking charge.
e restricted and repetitive behaviors progressively and
signicantly improve, remaining dierentiated between the two groups,
with a greater frequency and intensity in children with autism. In
restricted and repetitive interests inherent actions or play routine may
be present the awareness of the relationship with the other, although
with the rigidity that characterizes the mode of being in a relationship
that is typical of autistic children, as well as mannerisms of the hands and
of the whole body does not necessarily preclude relational aspects and
may be related to self-regulation and to the discharge of body tension.
Unusual interests directed to segments of sensory experience of self
and of objects, prevent the connection between sensory processing and
emotions, hindering the awareness of a psychological and emotional
relationship with the other.
Citation: Di Renzo M, Bianchi di Castelbianco F, Vanadia E, Petrillo M, Racinaro L, et al. (2016) From the Emotional Integration to the Cognitive
Construction: The Developmental Approach of Turtle Project in Children with Autism Spectrum Disorder. Autism Open Access 6: 160.
doi:10.4172/2165-7890.1000160
Page 8 of 9
Volume 6 • Issue 1 • 1000160
Autism Open Access
ISSN:2165-7890 AUO, an open access journal
Among the indicators of a positive evolution of autistic symptoms,
we identied improvements in the score of unusual sensory interests
and the presence of symbolic play, found in all children at the end of
four years of therapy who no longer fell within the ADOS criteria for an
autism spectrum diagnosis.
e improving of these areas indicates that the therapeutic work
that uses body mediation promotes the integration of monosensory
perceptions so that the various segments of sensory experiences can
gradually evolve into a rst emotional experience [29,32,33,73] that
activates a process of connection between emotions, sensory processing,
motor planning and the formation of symbols. Another element
indicative of positive diagnostic evolution, considered in this research,
is the improvement in IQ scores over the four years of therapy, because
information processing in interactive contexts integrates emotional
and intentional aspects which organize and enhance the activities and
cognitive function. e assessment of cognitive skills is, at the Institute
Ortofonologia, a fundamental element of the diagnostic process. And the
monitoring of the intellectual potential takes place in parallel with the
evaluation of those decit areas that are typical of autistic disorder [66].
We emphasize the fact that the project does not provide a
specically cognitive work before the 5 years of age, age at which are
less evident both the defences and processes which hinder the thinking
development in autism [1,4,5,71]. No structured cognitive work has
been proposed before 5 years, when the processes of imitation lay
the foundation for communication and relationship. In these phases
of development, therapy should focus on the psycho-physical area
[16,24,25,29,32,50], on the emotional blocks that are antecedents to
cognitive processes [49,51-53].
is study highlights the long-term eects of a therapy based on
a developmental approach on the symptomatic outcomes of children
with an autism diagnosis (across autism severity range). e results
reported in this study encourage clinicians to identify, from the moment
of diagnosis, social-relational aspects as key points on which centre the
therapy. To do this, it can be very useful also from a qualitative and
clinical point of view to use those diagnostic tools that are recognized
as more reliable (in our case the ADOS); in fact, the data show that
the work focused on social-relational aspects results fundamental
to achieve improvements in the cognitive sphere. Working on these
aspects allows the child to mature his self-regulation and interaction
abilities; during the four years of therapy in most of the children in
the sample progressively better results were achieved. e social and
relational areas, assessed with the ADOS, were the key areas on which
the therapy was based; the presence or absence of improvements in the
emotional and relational aspects so become predictors of a positive
evolution in autistic symptoms, and at the same time stimulate the
development of cognitive abilities.
Limitations
When children arrive at the assessment center and receive a
diagnosis of autism, they are soon included in the treatment plan.
is has not allowed us to combine the studied sample with a control
sample of children who were not included in any course of treatment.
Moreover, since the data were collected over a period of time during
which the ADOS-2 had not yet been published all assessments were
carried out with the ADOS rst edition.
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Citation: Di Renzo M, Bianchi di Castelbianco F, Vanadia E, Petrillo M,
Racinaro L, et al. (2016) From the Emotional Integration to the Cognitive
Construction: The Developmental Approach of Turtle Project in Children with
Autism Spectrum Disorder. Autism Open Access 6: 160. doi:10.4172/2165-
7890.1000160
... Among the developmental models, the DERBBI-Turtle Project (Developmental, Emotional Regulation and Body-Based Intervention for children with autism spectrum disorders) is the one being proposed. DERBBI represents an interactive developmental model with body mediation that integrates the theoretical aspects described in clinical activity that involves caregivers, and supports social development since the early years of life (Di Renzo et al., 2016a;Di Renzo et al., 2016b). This intervention is aimed at constructing communicative modes, it is mediated by the therapist and the caregiver who help the child to regulate their own reactions when confronted with external or internal stimuli that can be perceived as disturbing or harmful. ...
... The intervention also stimulates the child's understanding of the world around them through a bottom-up process that starts from the body and works upwards towards the mind. The therapy aims to stimulate cognitive and communicative abilities, although it does not provide an exclusively structured cognitive treatment before the age of 6, rather, it does so by integrating support for the mental and cognitive development within bodily and relational mediated activities (Di Renzo et al, 2016a). Therefore, in light of what has been illustrated thus far, the purpose of this study is to define theoretical-scientific and methodological assumptions of the DERBBI model while monitoring the development of the core symptomatology of autism. ...
... For many years, The Institute of Ortofonologia (IdO) has based its diagnostic and therapeutic processes for children with ASD, or at specific risk, on an integrated, multi-professional, developmentalrelationship-body mediated approach which is represented by the DERBBI method and Turtle Project (Di Renzo et al, 2016a;Di Renzo, 2017). This approach considers both of the interrelated cognitive and affective components (Alvarez, 2012;Bion, 1967;Freud, 1965;Stern, 2004;Winnicott, 1989). ...
Article
Full-text available
Autism spectrum disorder (ASD) is a neurodevelopmental disorder displaying individual impairments in social interaction, communication skills, interest and behaviours. In the last decade several studies have been published on the approaches that can be used with ASD children. This study illustrated the therapeutic approach of the DERBBI method, defined as a relational and body based intervention. The research described the symptoms and emotional development outcomes of ASD children aged 21–66 months, after 2 of the 4 years of planned therapy; the study group included both children who had received a diagnosis of autism and children (under 30 months) who had a risk of developing symptoms. Approximately 78% of the children with a more severe ASD symptomatology after two years of therapy maintained this diagnosis, instead, among children with a less severe ASD symptomatology, about the 67% after two years of therapy no longer fulfilled the ADOS-2 criteria for autism. Among the children who were at risk of developing the autistic symptomatology, about the 42% no longer showed this risk after 2 years of therapy. The improvements that the children showed in their ability to understand the intentions of others and to contact the emotions of others were also investigated. The findings of this study have underlined the importance of early positive indicators which, among the Autisms, could be defined a specific subpopulation that get better benefits from such a type of intervention.
... Within this model was developed a specific intervention for children with ASD: the Turtle Project. The Turtle Project [113] is an individualized intervention based on an individual's profile to use developmentally appropriate and meaningful targets. This profile is developed thanks to an accurate diagnostic process, including the TULIP protocol [114], for a comprehensive assessment of the predictors of positive outcomes in children with ASD. ...
... The Turtle Project is an example of a program that both reflects and contributes to the evidence base of autism interventions, through various studies that have shown an assessment protocol useful for capturing the complexity and the uniqueness of every child [114,116,117]. Furthermore, the studies deepening the effectiveness of the Turtle Project highlighted the protective factors identified during the diagnostic assessment and useful in predicting children's developmental trajectories and children for whom this type of treatment could lead to a greater improvement in symptoms [113,114,118,119]. Third, recent papers have brought new reflections on the need to customize the intervention according to the characteristics not only of the autistic disorder but above all of the child and his/her family. ...
... More specifically, in the 2015 paper [118] on a sample of 90 individuals with ASD aged between 2 years and six months and 16 years, data showed an improvement in autistic symptoms after 4 years of treatment. The 2016 paper [113] provided further data supporting the effectiveness of Turtle Project, indicating that after two and four years of treatment children exhibited a significant improvement in all assessed areas (speech and communication, mutual social interaction, play, restricted and repetitive behaviors, and Intelligence Quotient), in addition to a significant reduction in core autistic symptoms. ...
Chapter
Full-text available
Developmental approaches characterized interventions based on the typical sequences of the child's development, paying particular attention to the linguistic, motor and socio-emotional aspects, within a relational perspective. The purpose of this paper was to identify developmental interventions for children with Autism Spectrum Disorders (ASD) aged between 0 and 12 years old. A literature review was carried out searching on MEDLINE, PsycINFO, and PsycARTICLES and manually on key journals and reference lists of key articles [...] This review highlights the need for improved research on intervention programs and the important service needs for families and children with Autism Spectrum Disorders.
... In the Italian developmental approach called Turtle Project [35] the focus of the intervention is constituted from the body's relationship with the child that also involves parents in individual and/or group settings. The fundamental objective is to help parents to interpret the atypia of the child for creating a shared care that could form the basis for a first form of communication. ...
... To demonstrate how the bodily-affective dimension is crucial in the structuring of the autistic disorder and how it takes priority over the cognitive disharmony some studies [45] [46] [47] [48] highlighted, through the evaluation protocol called T.U.L.I.P. 1 , how a sample of 49 children, regardless of the ADOS score [49], showed a better ability to understand intentions and emotions of the others. By monitoring the group during 4 years of Turtle Project therapy [35] there was evidence that the results were significantly better as early as the end of the second year of therapy, compared with children who had a worse outcome at the T.U.L.I.P. protocol testing. As well as allowing the identification of the zone of proximal development, the T.U.L.I.P. protocol clearly shows that the main obstacle to the development is determined by the lack of those basic attunement mechanisms that are highlighted through the UOI and the TCE [47]. ...
... To get involved is what promotes the activation of the ludic area that should never be confused with the use of games for educational purposes but is constituted by shared action that generates pleasure and encourages to look for the other, in order to avoid those self-stimulations which, in absence of other, allow the child to experience few moments of rest. In a research conducted to assess the efficacy of the developmental approach [35], in a sample of 80 autistic children, significant improvements were founds in all developmental areas: significant change was found on Cognitive abilities (F2, 78 = 32.06, p < 0.001; η 2 = 0.29); on ADOS score (F2, 78 = 65.15; ...
Article
Full-text available
The roots of autism spectrum disorders become evident in first attunement mechanisms between mother and child that allow a first level of mentalizing. Neurosciences and current developmental theories confirm the existence of defensive mechanisms related to body and affectivity that psychodynamic theories had already highlighted. Reading child’s behavior not only by administering tests but also through careful clinical observations allows a better understanding of the communication and social difficulties present in autistic children. The identification of the zone of proximal development can promote a therapeutic intervention that respects the individuality of the child and the specificity of his relational approach to the world. Conclusion: The paper presents the theoretical principles of a bodycentered therapy to promote the attunement processes necessary to activate cognitive resources.
... With a view to integrate evaluation, therapy and research, we now regularly used it at the IdO to evaluate the longitudinal evolution of symptoms through re-tests during the years of treatment (Di Renzo et al., 2015;Di Renzo, Bianchi di Castelbianco, Petrillo, Donaera, Racinaro and Rea, 2016;. Our previous research (Di Renzo et al., 2016b) also demonstrated the clinical relevance at a longitudinal level of RRBs and above all their prognostic value, underlining their importance at a quantitative level in terms of frequency and intensity, in the various ADOS retests during the years of treatment. The results presented demonstrate the connection of these behaviours with the severity level and therapeutic efficacy of a body-mediated work on archaic processes, that prevent the functional and symbolic use of objects through a structuring of behaviours that limit communication and induce a stereotyped use of the body. ...
... In terms of integration between clinical research and longitudinal studies on therapeutic efficacy, the validity and diagnostic sensitivity of ADOS-2 is increased by the comparison score, as an indicator of severity that allows to compare the general level of symptoms related to autistic spectrum of the child, with that shown by subjects diagnosed with ASD of the same age and level of linguistic ability. Also the Leiter-R is used in our comprehensive assessment for children with ASDs as it has shown, in longitudinal studies on the efficacy of developmental relationship body-based intervention, the predictive value of fluid reasoning both on the progressive improvement of IQ expression and the reduction of autistic symptomatology after four years of therapy (Di Renzo et al., 2015, 2016b. These data support the hypothesis that a relationship-based approach allows cognitive improvement regardless of the severity of autism. ...
Article
Full-text available
Purpose The assessment of Autism Spectrum Disorders (ASD) in childhood has two essential aspects: the identification of the risk (under 30 months of age) and the definition of a diagnosis that takes into account its core areas as well as further non-specific aspects. The purpose of this paper is to present an approach that considers the combination of clinical evaluation with the use of tools that analyse the various levels of the child’s functioning as fundamental. Design/methodology/approach The comprehensive assessment at the Institute of Ortofonologia in Rome provides the ADOS-2 and the Leiter-R for the evaluation of the symptomatology, the severity level, the non-verbal cognitive functioning and the fluid reasoning; the TCE and the UOI are used to identify, respectively, the child’s emotional skills and the ability to understand the intentions of others, as precursors of the theory of mind. Within this assessment, the Brief-P, the Short Sensory Profile and the RBS are also included for the evaluation of executive functions, sensory pattern and of restricted and repetitive behaviours, as observed by parents. Findings How to define a reliable development profile, which allows to plan a specific intervention calibrated on the potential of the child and on his development trajectory, is described. Two clinical cases are also presented. Originality/value The entire process is aimed both at a detailed assessment of the child’s functioning and at identifying a specific therapeutic project and predictive factors for achieving an optimal outcome.
... autism spectrum disorders) for which traditional intelligence tests may not be appropriate or valid. In fact, it is a completely non-verbal scale and consists of two batteries: the first is the Visualization and Reasoning (VR) Battery which includes ten subtests, measuring nonverbal cognitive visuospatial and reasoning skills then generating Brief IQ (ages 2-20), Full Scale IQ (ages 2-20) and Fluid Reasoning Index (ages [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]; the second, that is the Attention and Memory (AM) Battery, which also consists of ten subtests that enhance the interpretation of the global nonverbal IQ score by providing valuable diagnostic indicators of speed and non-verbal memory. The two batteries can be administered together or separately. ...
... The first consideration concerns the presence of some deficiencies in children who, after a course of therapeutic treatment body-centred [11][12][13], obtained an ADOS score of no-autism. The main difficulty regards the relationship with the other's body, as well as their own, indicating that lack in communication originates in an initial lack of modulation of the body to environmental stimuli and then it is as if mother's attunement would not find in the child a fertile ground. ...
Article
Full-text available
Autism spectrum disorders (ASDs) are a class of neurodevelopmental disorders defined by qualitative impairments in social functioning and communication, often accompanied by repetitive and stereotyped patterns of behaviour’s and interests, with their typical onset during the first three years of life. Recent researches demonstrate that early diagnosis and intervention sensibly improve outcomes. Until now, a limit of the most common therapies has been to get poor results in approaching the relational and emotional difficulties that, finding their origin in the early interactions that the child has with the outside world, must take account of the body as first experiential and communicative channel for the new-born. Although the current assessment protocols provide for development scales and observation of motor skills, do not yet exist studies aimed at identifying characteristic psychomotor profiles and too little attention is paid to bodily dimension in therapeutic terms. The purpose of present paper is to examine the psychomotor profiles of 61 children diagnosed with ASD, analyse their specifies and correlations with symptoms and cognitive development. Results show that children with more severe impairment have greater troubles in modulating their body, in attention, in spatial organization, in symbolic play, in motor behaviour’s, starting from imitation, and in communication, even from the most archaic mode, namely the tonic dialogue. Findings, supported by what has already been published on the effectiveness of early developmental-relationship-bodily based approach with ASD children, support the idea that psychomotor area should represent an essential element in childhood rehabilitative therapies, especially in autism, where it is necessary to start from body and experience intended as a solid foundation on which build cognitive and social skills.
... For children evaluated between 2013 and 2016, the diagnosis of autism was based on the DSM-5 criteria [18], for which, in addition to clinical observations, the children were given the Autism Diagnostic Observation Schedule-second edition (ADOS-2) [19]. After receiving the diagnosis, all the children were included in a developmental therapy program for ASD [20,21]. At the end of the therapeutic path, among the children who no longer fell within the diagnostic classification of spectrum disorder, 17 were monitored over time, and on average after 5 years a direct assessment was proposed to identify autism spectrum disorder (clinical interview, observation, and ADOS-2) and an indirect assessment, through a questionnaire filled in by parents for the measurement of social and adaptive skills (ABAS-II) [22]. ...
Article
Full-text available
Autism spectrum disorders are generally regarded as lifelong conditions, affecting communication, relationships, and adaptive skills. Studies on the developmental trajectories of people out of autism have found adequate adaptive social-communication skills, effective experiences of inclusion in regular education classrooms, normal intellective functioning, and an absence of typical autism symptomatology. It therefore seems plausible to start reading the 'after autism' psychopathological conditions in a continuum that features several possible clinical and non-clinical phenotypes. The present retrospective research aimed to examine the different developmental trajectories of 17 children with an original diagnosis of autism, evaluated in a follow-up approximately 5 years after the end of the therapy. The stability of the optimal outcomes is evidenced by the absence of clinical diagnostic criteria for autism spectrum disorder. However, some difficulties persisted in adaptive functioning, especially in the social domain, consistent with the dysfunctional core that characterized the clinical features of autism in childhood. Furthermore, many of the participants showed residual relational atypia, such as alterations in pragmatic communication, or a psycho-affective disorder, or specific developmental disorders. The presence of some residual atypia provides important food for thought, not only in orienting any therapy with which continue to support older children, but also for a greater understanding of the pathological core towards which has evolved the original diagnosis of autism.
... There is therefore pressing need for a scalable, evidence-based intervention within public health services both in LMICs and most HICs. In Italy, reduced access to specialist professional training for clinicians in the public sector (Borgi et al., 2019), somewhat low cultural acceptance of behavioural methods, often poorly understood and deemed 'too rigid' as a whole (Cascio, 2015), and the lingering influence of a minority of supporters of psychoanalytic 'therapy' (Di Renzo et al., 2016) have the potential to threaten the uptake of behavioural teaching strategies embedded within naturalistic, developmentally oriented interactions. Yet, very little research has been conducted to examine cultural barriers, acceptability and actual feasibility of implementation of naturalistic developmental behavioural interventions (NDBIs; Schreibman et al., 2015) for neurodevelopmental disorders in public health settings in Italy or other European countries (Colombi et al., 2018;Holzinger et al., 2019). ...
Article
Lay abstract: Across the globe, children with neurodevelopmental disorders, including autism, have limited access to care through public services. To improve access to care the World Health Organization developed a novel, open-access programme: the Caregiver Skills Training programme. The Caregiver Skills Training consists of nine group sessions and three individual home visits, focused on training the caregiver on how to use everyday play and home routines as opportunities for learning and development. We implemented Caregiver Skills Training in public child neuropsychiatry services in Italy and examined with questionnaires and focus groups how feasible it was to deliver the programme in public health settings and how acceptable and relevant it was for caregiver users. We found that the Caregiver Skills Training was largely considered acceptable and relevant for families and feasible to deliver. We discuss potential solutions to address the specific implementation challenges that were identified, such as strategies to improve training of interventionists and overcome barriers to caregiver participation.
... These aspects should be addressed through intervention programs for parents. At the Institute of Orthophonology (IdO) support for parents has been incorporated into the D.E.R.B.B.I. intervention (known in full as the Developmental, Emotional Regulation and Body-Based Intervention) within the Turtle Project (Di Renzo et al., 2016). The project combines various interventions offered to children and parents including child assessment (Di Renzo et al., 2019), counseling for parents, clinical sessions with the professionals who work with the child, thematic seminars and experiential workshops, mothers/fathers-child in care settings, and groups of parents (Di Renzo et al., 2020a). ...
... These aspects should be addressed through intervention programs for parents. At the Institute of Orthophonology (IdO) of Rome, psychological support for parents has been incorporated into the D.E.R.B.B.I. intervention (known in full as the Developmental, Emotional Regulation and Body-Based Intervention) within the Turtle Project (Di Renzo et al., 2016). The project combines various interventions offered to children and parents including child assessment (Di Renzo et al., 2019), counseling for parents, clinical sessions with the professionals who work with the child, thematic seminars and experiential workshops, mothers/fathers-child in care settings, and groups of parents (Di Renzo et al., 2020a). ...
Article
Full-text available
Early parent–child relationships are an important factor influencing many domains of child development, even in the presence of autism. In this study, we investigated the associations between parent–child attunement during play, parental insightfulness, and parental acceptance of their child’s diagnosis of an autism spectrum disorder. A sample of 50 parents (26 mothers and 24 fathers) of 26 children aged between 24 and 58 months were videotaped during parent–child play interactions and then interviewed about what they thought had gone through their child’s head during the play interaction, and about their feelings and thoughts about their child’s diagnosis. Play interactions were evaluated using a coding protocol to assess parental attunement. The results showed that parents who were more able to accept their child’s diagnosis and to see things from their child’s perspective were more likely to also be attuned during play interactions with their children. These findings highlight the importance of studying the parental ability of insightfulness and acceptance of their child diagnosis of ASD for the implementation of intervention programs for supporting parental attunement and improving the interactions between the parents and the children with autism spectrum disorders.
... The spontaneous appearance of the drawing, in our experience, it is always a result of a greater relational opening of the child and then an expansion of the cognitive strategies necessary to adapt to the outside world. Recent researches [27][28][29] documented how generally the cognitive level and also intellectual inhibition are closely related to the ADOS score and if this decreases, thanks to the course of treatment, as a result the intellectual inhibition will reduce and the IQ score of the subject will increase. Similarly the autistic symptoms may block the drawing development, in the sense that serious symptoms correspond to a low IQ score and to a drawing level which strongly deviates from the norm. ...
Article
Full-text available
Objective: In developmental age the drawing process represents one of the best tools to assess the level of maturity reached by the child in his various areas of functioning. This study considers a sample of 84 children aged between 2.5 and 15 years, all diagnosed with autism, evaluated by an expert team of professionals, in order to highlight the drawing stage reached and the correlation with the severity of autistic symptoms assessed by the ADOS and cognitively evaluated with the Leiter-R nonverbal scale. Methods: The drawing level was observed in spontaneous production by establishing a scale ranging from the presence of the disordered scribbling to the presence of the body schema, taking into account the stereotypes that can lead to some echo-graphic representations that are similar to the echo-lalic productions of the verbal language. Results: The results showed a significant correlation between the drawing production and the Social-Affection component of the ADOS, so demonstrating that the delay in the drawing is heavily influenced by an emotional as well as intellectual inhibition. Conclusion: Through some examples of drawings it is also emphasized the relationship between drawing and chronological age and the difference that emerges between drawings made in the evaluation context and those that come to life during the therapeutic process.
Chapter
Winnicott’s preface to his book The Family and Individual Development gives a statement of its central topic: the family and the theory of the emotional growth of the human child. Winnicott proposes that the prototype of the place where the developing child meets society lies in the original meeting point for us all, the infant-mother relationship. Included are Winnicott’s acknowledgements for the book.