A young adult with nonverbal low-functioning Autism: A case review of readiness for independent living

Abstract

This is a case review of a male adult, GO, with nonverbal low functioning autism in his twenties. Previous psycho-educational assessment indicated that GO had a nonverbal IQ (NVIQ) of 73 within the borderline range, an adaptive behavior composite score at the extremely low percentile rank, and poor executive functioning (EF) capability with majority of the EF components falling in the performance range from borderline problem to problematic range. His family has expressed their concern if GO would be able to take care of himself when they are too old or no longer around to care for him. This short paper is an attempt to review all the previous assessment results and to find out if GO could be helped to improve in his daily living skills in order to lead a more independent life in the future.

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Asian J. Interdicip. Res. 162-177 | 162
A young adult with nonverbal low-functioning Autism: A case review
of readiness for independent living
Zuxin Josie OH a,*, Guo Hui, XIE b
a Educational Therapist, Stargazer Intervention Centre, Singapore
a Board-Certified Educational Therapist, Special Needs Consultancy& Services, Singapore
*Corresponding Author: josie.oh.8004@gmail.com
DOI: https://doi.org/10.34256/ajir20112
Received: 31-01-2020
Accepted: 07-03-2020
Abstract: This is a case review of a male adult, GO, with nonverbal low
functioning autism in his twenties. Previous psycho-educational assessment
indicated that GO had a nonverbal IQ (NVIQ) of 73 within the borderline
range, an adaptive behavior composite score at the extremely low percentile
rank, and poor executive functioning (EF) capability with majority of the EF
components falling in the performance range from borderline problem to
problematic range. His family has expressed their concern if GO would be able
to take care of himself when they are too old or no longer around to care for
him. This short paper is an attempt to review all the previous assessment
results and to find out if GO could be helped to improve in his daily living skills
in order to lead a more independent life in the future.
Keywords: Adaptive Behavior, Autism, Executive Function.
1. Introduction
Autism spectrum disorder (ASD), also
commonly known as autism, is a
developmental disability whose onset takes
place during toddlerhood around 2-3 years of
age. Children with ASD face problems in social
interaction, speech and nonverbal
communication, and restricted and repetitive
patterns of behaviors, interests or activities
(American Psychiatric Association, 2013).
One of the main concerns of parents
and/or caregivers of children with autism is
that one day they (parents or caregivers) will
get old and are no longer as physically fit as
before to take care of their adult child with
special needs. The question that has kept
popping in their head is: “Will their adult
children be independent enough to complete
their daily activities such as purchasing food,
washing up, dressing up, and travelling from
place to place?”
These daily activities constitute a
portion of the overall adaptive behavioral
skills, also known as social competence (i.e.,
responsibility and accountability),
independent living, adaptive behavioral
functioning, independence, or life skills that a
person needs to perform everyday tasks. In
fact, adaptive functioning is affected by three
basic skill sets (MentalHelp.net, 2019): “(1)
Conceptual – This includes reading, numbers,
money, time, and communication skills; (2)
Social – These skills help a person to get along
DOI: 10.34256/ajir20112
REVIEW

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Asian J. Interdicip. Res. 162-177 | 163
with others. These skills include
understanding and following social rules and
customs, obeying laws, and detecting the
motivations of others in order to avoid
victimization and deception; and (3) Practical
life skills – These are the skills needed to
perform the activities of daily living. This
includes feeding, bathing, dressing,
occupational skills, and navigational skills”
(para.3-6).
2. Brief Background of GO
GO
1
is currently 25 years 4 months and
was born into a Chinese family in Singapore.
He has an older sister and his family
communicates to him mainly in English.
However, sometimes Chinese and/or the
Hokkien dialect are used when talking to GO,
too.
GO first showed signs of developmental
delay at 6 months old when he did not look for
the yarn when asked to, did not pass cubes
from hand to hand, did not produce single
syllable words and could not imitate speech
sounds. He was later referred to a psychiatrist
and a speech therapist at 3 years of age when
he was found to have a severe speech delay.
The Bayley Scales of Infant
Development-2nd Edition (BSID-2) (Bayley,
1993) was administered by a speech therapist
when GO was 3 years 1 month old. The raw
score for his mental development was 123. It
was observed that he lacked social
communication skills, imaginative play and
had ritualistic behavior. At 5 years 5 months
old, he was diagnosed with ASD after the
Autism Diagnostic Observation Schedule
(ADOS) (Lord et al., 1989; Lord et al., 2000),
which is an instrument for diagnosing and
assessing autism, was administered. His
mother continued to send him for speech
1
GO is the initials of the client’s name. His full name has
been kept anonymous to abide with the requirements of
the Personal Data Protection Act 2014 in Singapore.
therapy as well as other therapies such as
occupational therapy and early intervention.
GO developed seizures at the age of 13
years and has since been on anti-convulsant
medication. His mother and older sister have
consistently observed him and they soon
realize that his seizures are usually triggered
when he is stressed, especially when it is due
to changes in his surroundings and/or also
when he does not have enough sleep.
GO is currently attending a learning
center run by a voluntary welfare organization
five times a week. During his time there, GO
uses the Picture Exchange Communication
System (PECS) (Bondy & L.A. Frost, 1994;
Bondy & L.A. Frost, 2001), which he has been
trained to apply in communicating with his
coaches, and viewing and completing his daily
and weekly tasks (e.g., meal preparations and
newspaper collection). He makes choices
independently whenever he is allowed to and
gets rewarded with activities that he is fond of
when he completes his tasks on time.
At home, GO is able to perform several
daily chores independently (e.g., making his
bed, washing up, getting dressed, bathing,
cooking instant noodles, making beverages,
cutting things with a knife and folding, hanging
and keeping of clothes). He is also able to
respond to single words such as ‘more’,
‘faster’, ‘gentle’, ‘on’, ‘off’, ‘open’, ‘close’ and
‘help’.
However, GO still needs guidance or
supervision in brushing his teeth, knowing the
exact amount of money to pay and is still
unable to travel independently using the
public transport.
3. Diagnostic Assessment
Several assessments were administered
on GO in the past. Most of them were based on
the Hierarchy of Abilities and Skills as
postulated by Chia (Chia, 2012) and the
framework is briefly described below (also see
Figure 1):

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Asian J. Interdicip. Res. 162-177 | 164
Table 1. Hierarchy of Building Blocks of Skills & Abilities
Hierarchy
of Blocks
Skills & Abilities (S&A)
Primary
Measure
Secondary
Measure
Additional
Measure
Block I
Innate S&A
TONI-3
--
--
Block II
Sensory Perceptual-Motor
Behavioral S&A
SP-AA,
SP-CQ
SP-SS,
SP-Supple
--
Block III
Adaptive Behavioral S&A
ABDS
--
--
Block IV
Social-Emotional
Behavioral S&A
--
--
--
Block V
Cognitive Behavioral S&A
LEAF
--
--
● Foundation Block of innate abilities (e.g.,
WISC-IV): The Foundation Block refers to
the core block of an individual's innate
abilities which deal with the use of
language to communicate, abstract
thoughts and reasoning skills, memory
retention as well as problem solving skills.
An example of an assessment tool for this
level is an IQ test such as Test of Nonverbal
Intelligence-Third Edition (TONI-3)
(Brown et al., 1997).
● Block II of sensory perceptual-motor
processing and coordination skills and
abilities: Block II focuses on the sensory-
perceptual-motor coordination and related
behavioral skills and abilities involving
balance/motion of the body (vestibular) &
position of body (proprioception). An
example of an assessment tool for this level
is the Sensory Profile (SP) (Brown & Dunn,
2002; Dunn, 1999; Dunn, 1999).
● Block III of adaptive behavioral skills and
abilities: Block III concerns the adaptive
Figure 1: Hierarchy of Skills and Abilities

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Asian J. Interdicip. Res. 162-177 | 165
behavioral skills and abilities such as
activities of daily living, social interaction,
communication, self-help skills (e.g.
toileting, dressing, bathing), personal
hygiene and other related practical skills.
An example of an assessment tool for this
level is the Adaptive Behavior Diagnostic
Scale (ABDS) (Pearson, 2016).
● Block IV of social-emotional skills and
abilities: Block IV consists of socio-
emotional behavioral skills and abilities
which cover adaptive, internalizing and
externalizing behavioral skills. This level of
skills and abilities can also be determined
by assessment tools such as ADHD Rating
Scale-IV (DuPaul, 1998) and Gilliam Autism
Rating Scale-3rd Edition (Gilliam, 2013).
Block V of cognitive skills and abilities:
Block V focuses more on academic or
educational attainments, which include higher
levels of cognition, involving word knowledge
(i.e. active and passive vocabularies), general
knowledge, ability to count and perform
operational functions involving numbers and
ability to carry out activities using both verbal
and nonverbal reasoning skills. Most of the
assessment tools are academic attainment
measures such as the Aston Index-Revised
(Newton & M. Thomson, 1982) and Neale
Analysis of Reading Ability-Second Edition
(NARA-2) (Neale, 1997).
4. Results and Discussion
In this section, the results obtained
over two years, i.e., 2018-2019, are briefly
discussed in detail below.
4.1 Autism Diagnostic Observation
Schedule – Generic (ADOS-G)
The ADOS-G (DiLavore et al., 1995) is a
semi-structured, standardized assessment of
four domains, i.e., social interaction,
communication, play, and imaginative use of
materials, for individuals suspected of having
ASD. Its observational schedule consists of
four 30-minute modules. Each module is
designed to be administered to an individual
according to his/her level of expressive
language.
GO was assessed by a clinical
psychologist using ADOS-G at the Behavioral
Intervention Centre for Children (BICC), which
was managed by the Autism Research Centre
in the National University of Singapore, and he
was found to meet the criteria of autistic
disorder. No other information was provided
except a statement stating autistic disorder
was present.
4.2 Autism Diagnostic Interview TM-Revised
(ADITM-R)
The ADITM-R (Rutter et al., 1994) was
also used. This test is the 2003 revision of the
ADITM. It involves interviewing the client’s
parents or primary caretakers with the
knowledge about the individual’s current
behavior and developmental history. The
questions in ADI-R address the triad of
symptoms related to ASD: (1) Language
Communications; (2) Reciprocal Social
Interactions; and (3) Restricted, Repetitive,
and Stereotyped Behaviors and Interests. The
measure consists of 93 yes/no questions
followed by probe questions that are scored on
a scale of 0-2. The scores are then converted
into diagnostic criteria based on the
International Classification of Diseases-10th
Revision (ICD-10) (World Health Organization,
1992).
As mentioned earlier above, the former
and latter tests were administered by a clinical
psychologist at the Behavioral Intervention
Centre for Children (BICC) managed by the
Autism Research Centre in the National
University of Singapore. GO was then six years
of age. The results showed that GO scored
above the cut-off range of the autistic
population in the areas of communication,
social relations and restricted, repetitive
behaviors on both ADI-R (Rutter et al., 1994)
and ADOS-G (DiLavore et al., 1995). GO was
confirmed with the diagnosis of autistic
disorder. In addition, he exhibited short
attention span and had undergone Integrated
Playgroup Program offered at the BICC. Tables

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2 and 3 below show his results for both the
ADI-R (Rutter et al., 1994) and the ADOS-G
(DiLavore et al., 1995).
Table 3. ADOS-G Results
Category
Cut-off Scores
GO’s Scores
Social Interaction
7
20
Communication
4
10
4.3 Test of Nonverbal Intelligence, Third
Edition (TONI-3)
The TONI-3 (Brown et al., 1997) is a
norm-referenced nonlinguistic problem-
solving ability assessment tool used. It is
suitable with individuals who have severe
spoken language disorders, deaf or hearing
impaired, non-English speakers, or English-
language learners. It is used to assess the
cognitive, language, or motor impairments due
to neurological conditions. It also helps to
identify individuals suspected of intellectual
impairment. Since GO is non-verbal, the TONI-
3 (Brown et al., 1997) was chosen to better
understand his cognitive abilities. It was
administered when GO was 24 years 2 months
and the results are shown below in Table 4.
It was found that GO’s NVIQ is 73 which
falls in the borderline IQ range of 70 to 79
(Cooijams, 2005). This suggests that he faces
some neurological challenges (Exkorn, 2005)
which include problem-solving skills, attention,
memory, mathematics, visual comprehension,
reading, linguistic skills, and verbal
comprehension. Hence, there is a limit to the
amount of knowledge that GO can learn and he
would face difficulty with activities such as
using the telephone, banking, filling up forms
and identifying the correct bus service to get
home unless being taught and given assistance
from others which include but not limited to
family members, coaches and community
caregivers.
Table 4. TONI-3 Results
Scores
Age Equivalence
7:00
Deviant Quotient
73
Percentile Rank
4%ile
4.4 Sensory Profile (SP)
The Sensory Profile-Adolescent/Adult
(SP-A/A) (Brown & W. Dunn, 2002) and the
Sensory Profile-Caregiver Questionnaire (SP-
CQ) (Dunn, 1999) were both administered in
Table 2. ADI-R Results
Category
Cut-off Scores
GO’s Scores
Social Interaction
10
26
Communication
8
15
Repetitive Behavior
3
6

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August 2019 and 30 March 2019 respectively.
A Sensory Profile-Summary Score Sheet (SP-SS)
(Dunn, 1999) and a Sensory Profile-
Supplement (SP-Supple) (Dunn, 2006) were
used to further compute the results of the SP-
CQ (Dunn, 1999). Both the SP-A/A (Brown &
W. Dunn 2002) and the SP-CQ (Dunn, 1999)
measure the sensory processing on an
individual’s daily performance patterns by
providing information about his/her
tendencies to respond to stimuli and which
sensory systems are likely contributing or
creating barriers to functional performance.
The SP-CQ (Dunn, 1999) contains some
125 items that are organized into three main
sections:
(1) Sensory Processing: It contains six item
categories that measure an individual’s
responses to possessing of sensory inputs
via auditory, visual, vestibular, tactile and
oral processes;
(2) Modulation: It contains five item categories
that measure the individual’s ability to
monitor and regulate information to
generate an appropriate response to the
situation; and
(3) Behavioral and Emotional Responses: It
contains three item categories that
measure children’s emotional and
behavioral responses to sensory
experiences.
The SP-A/A (Brown & W. Dunn, 2002)
and SP-CQ (Dunn, 1999) allow us to
understand GO’s sensory processing patterns
and their effects on his ability to perform daily
activities. Both tests were completed by proxy
involving his mother, the primary caregiver,
and his sister who helps out in taking care of
him.
Below is the tabulation of the results
obtained from the administration of the
following SP-A/A (Brown & W. Dunn, 2002)
and the SP-CQ (Dunn, 1999).
GO showed typical performance for his
sensory processing (A to F). He displayed
probable differences, being less than others, in
two sections of his behavior and sensory
modulation, i.e., (H) modulation related to
body position and movement, and (K)
modulation of visual input affecting emotional
responses and activity level. This means he
showed weaker proprioception (i.e. perception
or awareness of the position and movement of
the body) and hence poor sense of bodily
awareness and, in turn, affecting his
movement (for item H), and also his emotional
state and activity level (i.e. his way of
expressing his daily physical activity) were
less affected by visual input.
GO's main problem (definite difference
or “much less than others”) could be seen in
his very low (I) modulation of movement
affecting his activity level. His poor
proprioception indicates lower awareness of
emotional and non-emotional internal bodily
signals. This problem is associated with
alexithymia (Luminet, 2018). However,
evidence suggesting that alexithymia
modulates body awareness at an external level
is scarce (Luminet, 2018), and it is associated
with difficulties perceiving some non-affective
interoceptive signals, such as interpreting
signals of hunger, arousal, proprioception,
tiredness and temperature (Brewer, 2016).
According to Brewer, Cook and Bird (Brewer,
2016), alexithymia is a sub-clinical construct,
traditionally characterized by difficulties
identifying and describing one's own emotions.
Being non-verbal, GO could feel frustrated
whenever he attempted to express his
emotions and nobody understands him.
GO's low sensory seeking based on the
2018 SP-CG administration agreed with the
2019 SP-A/A administration while his
sedentary disposition suggested that he is very
much an autistic introvert (Xie, 2019),
preferring to be left alone and to do his own
things.
GO's overall scores based on the
administration of Sensory Profile-
Adolescent/Adult Version (SP-A/A) (Brown &
Dunn, 2002) in August 2019 and the earlier
Sensory Profile-Supplement Version (SP-
Supple) (Dunn, 2006) in March 2018 were
37/75 under the category of “less than most
people” (SP-A/A) (Brown & Dunn, 2002) and
83/85 under the category of “less than others
with probable difference” (SP-Supple) (Dunn,
2006), respectively.

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Table 5. SP-A/A Sensory Sub-Domain Results
Sensory Sub-Domains
Score
Percentage
Descriptor
A. Taste/Smell Processing
18/40
45%
Occasionally
B. Movement Processing
9/40
22.5%
Seldom
C. Visual Processing
20/50
40%
Seldom
D. Touch Processing
26/65
40%
Seldom
E. Activity Level
23/50
46%
Occasionally
F. Auditory Processing
28/55
50.9%
Occasionally
Table 7. SP-CQ Sensory Processing Results
Sensory Processing
Scores
Percentage
Descriptor
A. Auditory Processing
31/40
77.5%
Seldom
B. Visual Processing
35/45
77.8%
Seldom
C. Vestibular Processing
55/55
100%
Never
D. Touch/Haptic Processing
82/90
91.1%
Never
E. Multisensory Processing
32/35
91.4%
Never
F. Oral Processing
50/60
83.3%
Never
Table 8. SP-CQ Sensory Modulation Results
Sensory Modulation
Score
Percentage
Descriptor
G. Sensory Processing related to Endurance
Tone
41/45
91.1%
Never
H. Modulation related to Body Position &
Movement
50/50
100%
Never
I. Modulation to Movement affecting Activity
Level
35/35
100%
Never
J. Modulation of Sensory Input affecting
Emotional Responses
16/20
80%
Seldom
K. Modulation of Visual Input affecting
Emotional Responses & Activity Level
20/20
100%
Never
Table 6. SP-A/A Quadrant Results for Ages 18-64 years old
Sensory Quadrant
Score
Range of Scores
Descriptor
Low Registration
26/75
24-35
Similar to most people
Sensation Seeking
37/75
36-42
Less than most people
Sensory Sensitivity
29/75
26-41
Similar to most people
Sensation Avoiding
32/75
27-41
Similar to most people

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Table 10. SP-Supple Section Summary
Section
Score
Range of
Scores
Descriptor
A. Auditory Processing
31/40
38-30
Similar to others/ Typical
performance
B. Visual Processing
35/45
41-32
Similar to others/ Typical
performance
C. Vestibular Processing
55/55
55-48
Similar to others/ Typical
performance
D. Touch/Haptic Processing
82/90
88-73
Similar to others/ Typical
performance
E. Multisensory Processing
32/35
33-27
Similar to others/ Typical
performance
F. Oral Processing
50/60
59-46
Similar to others/ Typical
performance
G. Sensory Processing
related to Endurance
Tone
41/45
45-39
Similar to others/ Typical
performance
H. Modulation related to
Body Position &
Movement
50/50
50
Less than others/ Probable
difference
I. Modulation to Movement
affecting Activity Level
35/35
35-34
Much less than others/ Definite
difference
J. Modulation of Sensory
Input affecting Emotional
Responses
16/20
20-16
Similar to others/ Typical
performance
K. Modulation of Visual
Input affecting Emotional
Responses & Activity
Level
20/20
20
Less than others/ Probable
difference
L. Emotional/Social
Responses
77/85
79-63
Similar to others/ Typical
performance
M. Behavioral Outcomes of
Sensory Processing
29/30
30-29
Less than others/ Probable
difference
N. Items Indicating
Thresholds for
Responses
15/15
15-12
Similar to others/ Typical
performance
Table 9. SP-CQ Behavior and Emotional Responses
Behavior and Emotional Responses
Score
Percentage
Descriptor
L. Emotional/Social Responses
77/85
90.6%
Never
M. Behavioral Outcomes of Sensory
Processing
29/30
96.7%
Never
N. Items Indicating Thresholds for
Responses
15/15
100%
Never

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Table 11. SP-Supple Factor Summary
Factor
Score
Range of
Scores
Descriptor
1. Sensory Seeking
83/85
85-82
Less than others/ Probable difference
2. Emotionally Reactive
72/80
74-57
Similar to others/ Typical performance
3. Low Endurance/Tone
41/45
45-39
Similar to others/ Typical performance
4. Oral Sensory Sensitivity
35/45
44-33
Similar to others/ Typical performance
5. Inattention/Distractibility
28/35
32-25
Similar to others/ Typical performance
6. Poor Registration
40/40
40-33
Similar to others/ Typical performance
7. Sensory Sensitivity
20/20
20-16
Similar to others/ Typical performance
8. Sedentary
20/20
20-18
Less than others/ Probable difference
9. Fine Motor/Perceptual
14/15
15-10
Similar to others/ Typical performance
Most of the items scored for Sensation
Seeking were scored “almost never” in SP-A/A
(Brown & Dunn, 2002) or “never” in SP-CG
(Dunn, 1999) based on the scores evaluated
using the SP-Supple (Dunn, 2006).
The phrase “almost never” (in SP-A/A)
(Brown & Dunn, 2002) means that when GO
was “presented with the opportunity, he
almost never responded in this manner (about
5% or less of the time)” (Brown & Dunn, 2002).
The other phrase “never” (in SP-CG) (Dunn,
1999) means that when GO was “presented
with the opportunity, he never responded in
the manner, 0% of the time” (Dunn, 1999).
In other words, GO displayed “less than
most people” in his sensation seeking. This
means he has low sensation seeking. The
opposite of low sensation seeking is high
sensation seeking. According to (Zuckerman,
1978) and (Zuckerman et al., 1964), they
hypothesized that people who are high
sensation seekers require a lot of stimulation
to reach their Optimal Level of Arousal. “When
the stimulation or sensory input is not met, the
person finds the experience unpleasant”
(p.223) (Larsen & Buss, 2008).
The term, Sensation Seeking, is a
personality trait defined by the search for
experiences and feelings, that are varied, novel,
complex and intense (Zuckerman, 2009), and
by the readiness to take physical, social, legal,
and financial risks for the sake of such
experiences (Masson et al., 2019). Risk is not
an essential part of the trait, as many activities
associated with it are not risky. However, risk
may be ignored, tolerated, or minimized and
may even be considered to add to the
excitement of the activity (Zuckerman, 2009).
The concept was developed by
Zuckerman, Eysenck and Eysenck (Zuckerman
et al., 1978) for the Sensation Seeking Scale in
order to assess this trait. This test assesses
individual differences in terms of sensory
preferences. So, there are people who prefer a
strong stimulation and display a behavior that
manifests a greater desire for sensations and
there are those who prefer a low sensory
stimulation. The scale is a questionnaire
designed to measure how much stimulation a

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person requires and the extent to which they
enjoy the excitement. This measure was not
available at the time of assessment for GO and
hence, it was not done.
4.5 Adaptive Behavior Diagnostic Scale
(ABDS)
The ABDS (Pearson et al., 2016) is “an
interview-based rating scale that is used to
assess adaptive behavior of individuals for
ages 2 through 21 years … [Its] function … is to
establish the presence and magnitude of
adaptive behavior deficits” (p.1) (Pearson et al.,
2016). The results of the ABDS administration
provides both the therapist working with the
client and the client’s parents a better
understanding of the client’s daily
functionality, especially relating to the
practical tasks under the category of Daily
Living Skills (Bal et al., 2015).
The ABDS provides information on the
following three domains (Pearson, 2016)
(p.23):
(1) Conceptual Domain: It measures skills in
language, reading, writing, mathematics,
reasoning, knowledge and memory.
(2) Social Domain: It measures empathy, social
judgment, gullibility, communication skills,
the ability to make and retain friendships,
and similar interpersonal capabilities.
(3) Practical Domain: It measures self-
management personal care, home living,
community use, job responsibilities, money
management, recreation, and organizing
school and work tasks.
Raw scores obtained in the ABDS are
converted into domain index scores, percentile
ranks and age equivalents. An adaptive
behavior composite (ABC) index score is
computed from the sum of the three domain
index scores. The descriptive terms that
correspond to the domain and composite
scores are as shown in Table 12 below:
GO's ABC score of 35 lies within the
extremely low range which implies that he
would experience severe challenges in
effective communication with his
surroundings and needs close guidance and
monitoring when communicating with others
and if he were to live on his own.
4.6. Socio-Emotional Skills & Abilities
Socio-emotional development includes
a child's ability to engage with others to
establish a positive relationship, as well as the
child's experience, expression and
management of emotions (Cohen et al., 2005).
The emotional development aspect includes
the ability to identify and comprehend not just
one's emotions but also those of others in
order to empathize them and to establish and
maintain relationships with them. “It also
encompasses the management of strong
emotions and expressing them in a
constructive manner, and to regulate one's
behavior” (p.2) (National Scientific Council on
the Developing Child Winter, 2004).
According to a study by Dyck, Ferguson
and Shochet (Dyck et al., 2001), the empathy
ability of children with Autism Disorder is the
lowest when compared to children with
Asperger's Disorder and those with no
psychological disorder. In the studies of the
Theory of Mind (ToM) which is the ability to
attribute mental states of mind, Chia and Chua
(Chia & Chua, 2014) suggests that one should
view a person with an autistic mind as
someone whose ToM has stronger mind-
blindness (the inability to attribute mental
states of mind which causes one to be unaware
of others' mental states) and deeper
mindlessness rather than a faulty ToM.
Although no test was administered,
these studies suggest that GO will face
challenges socio-emotionally but there might
be a way to help with his poor mindsight and
extremely weak mindfulness (Chia & Chua,
2014).
4.7. Learning, Executive and Attention
Functioning Scale (LEAF)
The LEAF (Kronenberger et al., 2016) is
an assessment tool that measures the
neuropsychological abilities related to
executive functioning and learning. The LEAF
consists of 3 major areas used to assess the
overall functioning of the child.

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Table 12. Domain and Composite Scores and their Respective Descriptive
Terms
Domain & Composite Scores
Descriptive Terms
>109
Above average
90-109
Average
80-89
Low average
70-79
Low
55-69
Very Low
<55
Extremely low
Table 13. ABDS: Domain Index Results
Subscales
Raw
Score
Index
Score
SEM
Percentile
Rank
Descriptor
Age
Equivalent
Conceptual
Domain
78
40
(4)
<1
Extremely
Low
4 - 5 years
Social
Domain
73
40
(4)
<1
Extremely
Low
2 - 8 years
Practical
Domain
94
48
(4)
<1
Extremely
Low
8 - 9 years
Table 14. ABDS: Adaptive Behavior Composite Index Score Results
Sum of Index
Scores
Composite
Index Score
SEM
Percentile
Rank
Descriptor
Adaptive
Behavior
Composite (ABC)
128
35
<1
Extremely
Low
Table 15. LEAF Results
Subscales
Scores
Interpretation
A. Cognitive Learning
1. Comprehension & Conceptual
Learning
10
Problem
2. Factual Learning
10
Problem
B. Cognitive - Executive Functioning
3. Attention
9
Borderline Problem
4. Processing Speed
10
Problem
5. Visual-Spatial Organization
2
No Problem

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6. Sustained Sequential Processing
6
Borderline Problem
7. Working Memory
7
Borderline Problem
8. Novel Problem Solving
10
Problem
C. Academic
9. Mathematics Skills
5
Borderline Problem
10. Basic Reading Skills
11
Problem
11. Written Expression Skills
14
Problem
The first part is the Cognitive Learning
where it looks into the conceptual and factual
learning. The second part refers to the
Cognitive-Executive Functioning where
processing speed of the child, ability to solve
novel problems and memory are assessed. The
last part deals mainly with Academics like
reading, writing and mathematics skills.
Depending on the scores given, they are
categorized under as no problem, borderline
problem range to problem range. These
descriptions give information with regard to
the delays and disturbances (Kronenberger et
al., 2016) in the executive functioning and
learning of an individual.
The results above show that GO faces
problems with comprehension and conceptual
learning, factual learning, processing speed,
novel problem solving, basic reading skills and
written expression skills. Problems in these
subscales indicate that GO will face challenges
in literacy which in turn affects his reasoning
and the way he processes information.
GO has borderline problems in
attention, sustained sequential processing,
working memory and Mathematics skills. A
study by Kercood, Grskovic, Banda, and
Begeske (Kercood et al., 2014) shows that
individuals "with autism have been found to
score lower on measures of working memory
than do typical controls especially on task that
require cognitive flexibility, planning, greater
working memory load, and spatial working
memory, and with increasing task complexity
and in dual task conditions" (p.1316). It was
also reported that "lower scores in verbal
working memory were associated with greater
problems in adaptive behavior and more
restrictive and repetitive behavior" (p.1316)
(Kercood et al., 2014).
5. Discussion
Adaptive behavioral skills and abilities
is an essential learning process which refers to
“the effectiveness or degree with which an
individual meets the standards of personal
independence and social responsibility
expected of his/her age and social group”
(p.11) (Grossman, 1973). This broad spectrum
of skills and abilities are learnt and acquired
through the entire lifespan of an individual.
The adaptive behavioral process of
learning affects one’s sensory-motor skills,
communication skills, self-help skills and
social skills during infancy and early childhood
(Dunn, 1997). At late childhood and early
adolescence, with this block of skills and
abilities, one would be able to apply the basic
academic skills learnt in everyday life activities,
apply appropriate reasoning and judgment of
the environment and in his/her social skills. As
he/she proceeds on to the later stage of
adolescent and early stage of adulthood,
he/she would have to acquire the skills and
abilities concerning vocational and social
responsibility and performance (Gilotty, 2002).
From the results of LEAF, it clearly
indicates that GO will face issues
communicating with people around him due to
the challenges he faces in his academics as well
as him being non-verbal. From the information

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Asian J. Interdicip. Res. 162-177 | 174
provided by GO's mother, GO, to some extent,
could be considered quite independent and it
also suggested that he could process
information cognitively. However, the results
must be taken with caution as there is a high
chance of confirmation bias, i.e., an individual’s
tendency to search for, interpret, favor, and
recall information in a way that affirms
his/her prior beliefs/hypotheses. It is
considered a kind of cognitive bias and a
systematic error of inductive reasoning.
During an interview, GO's mother
shared with these authors the following
information:
(1) Whenever she goes to bathe at night, GO
would quickly cook a packet of instant
noodles, not forgetting to crack an egg, and
finishes it before she gets out of the
bathroom. However, at times, before he
finishes the noodles, he would clear his
bowl and washes the utensils used upon
hearing the bathroom door open.
(2) He has a habit of soiling his pants in order
to play with soap and water while washing
his pants. He would always do it whenever
she is in the bathroom.
(3) Whenever he bumped onto his mother or
sister, GO applies medicated oil or cream
on their injury or when they told him that
it was "pain" on a particular area.
(4) Sometimes when they are having their
meals, GO would observe how his family
members eat or what they take and would
"copy" them and do the same.
(5) GO was able to stay calm whenever he
listens to his favorite songs. He would
usually be rewarded with some time spent
at the relax corner with the radio at the
learning center.
On another occasion, GO's sister also
realized that whenever their mother sang the
first line of "Old MacDonald had a farm", GO
would quickly finish up what he was doing.
However, when the song was not sung, he
would continue to do what he preferred to do
despite the constant prompt of "faster".
The above examples showed that GO is
able to empathize
2
, mentalize
3
, mirror
4
,
systemize
5
, contextualize
6
, ruminate
7
and
dissociate/associate
8
which are the factors
used to train children and adults with special
needs.
6. Conclusion
By comparing the results obtained from
a broad range of standardized tests reported
previously by Wong and the sharing of GO's
mother, the authors of this paper concluded
that GO continues to show himself to be
sensitive to auditory triggers. Hence, music
could be used as either (1) a reward for him
whenever he does his task quickly or (2) a
deterrent to stop him from doing something
that is considered bad or negative.
Despite having an overall challenging
issue in his executive functioning, GO is still
able to follow instructions given pictorially
(via PECS cards) at the learning center where
he learns how to cook different dishes.
Moreover, GO is able to remember or recall the
steps taught by his mother to cook instant
noodle independently. It suggests that GO is
trainable, i.e., once he is familiar with the steps
as in the cooking procedure, he is able to do it
independently without any visual prompts.
2
Empathizing is defined as the process of identifying
another individual’s emotions and thoughts, and
responding to these with an appropriate emotion [42].
3
Mentalizing is defined as the process of attributing the
mental states to others or another individual [42].
4
Mirroring (also known as mimicking) is defined as the
process of observing an action and then performing an
equivalent action [42].
5
Systemizing is defined as the process of analyzing the
variables in a system, deriving the underlying rules that
govern the behavior of the system in order to construct,
reconstruct or deconstruct it [42].
6
Contextualizing (also known as context processing) is
defined as an ability of contextual sensitivity in
responding appropriately to a stimulus within its
context [42].
7
Ruminating is repeated thinking or thoughts [42].
8
Dissociating is defined as the process of separating
normally related mental/cognitive processes, resulting
in one group of mental and/or cognitive processes
functioning independently from the others or the rest
[42].

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Asian J. Interdicip. Res. 162-177 | 175
In addition, GO is very good at
mirroring others' actions which would enable
him to pick up skills quicker than others who
are weaker in this aspect. Hence, GO is able to
learn and acquire vocational skills that would
not only make him more independent, but,
hopefully, with the necessary skills acquired,
could prepare him in terms of vocational
readiness and/or employability to get a job in
the future.
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Declaration of Interest: The author declares that no conflict of interest related to this article
Acknowledgments: The author wishes to thank the family of GO for the kind permission to use
the psychological data obtained from the psycho-educational assessment in writing this paper for
the purpose of professional dissemination of knowledge.
Funding: NIL
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