**1. Introduction**

Making citizens is a major objective of contemporary education systems. Citizenship at first glance seems to be a complex concept and an extremely demanding educational process. The questions one might initially ask are: what does citizenship mean; how is it built; how is it taught; through what means and materials; what are its aims; what qualifications should those who teach it have; what age groups of pupils are concerned; how are curricula for citizenship designed; is the content oriented locally, regionally or globally; what is its relationship to sustainability and sustainable development?

In terms of curricula, this objective appears in two forms: either as a crosscurricular goal or process or as a distinct school subject with its own syllabus. Recent views of citizenship education academics, however, are not in favour of either of these approaches. They argue that for the desired outcomes to be achieved, citizenship

education should be both a cross-curricular goal and a distinct cognitive domain, with its own materials and with specific time and space allocated to it in the educational process. The content of citizenship education today focuses on the development of an autonomous personality that is characterised by a democratic political identity and an understanding of and respect for diversity and 'otherness' [1, 2]. Sustainability is arising as a contemporary political value and curricula are oriented to conclude related content and activities.

The fact that nation building was a necessary precondition for the development of modern education systems can explain, to a certain extent, the ethnocentric orientation of education and the strengthening of national identity it has brought about. Nonetheless, this trait imposes constraints on the formation of a democratic political identity with a global view, and it restricts understanding of social pluralism and multiculturalism [2].

The ability to live together in a democracy does not come naturally, it is an experiential and a spiritual process. The knowledge, skills and values that are the preconditions of living in a democracy should be learnt from early years to the adulthood. The components of citizenship education are school climate, curriculum and teaching strategies, pedagogy in the community and making the school a civil society forum. As Paulo Freire proposes, the schools should facilitate the practice of freedom, the means by which men and women deal critically and creatively with reality and discover how to participate in the transformation of the world [3].

The traditional curricula, promoting the 3Rs (Reading, Writing, Arithmetic), do not seem to suffice to respond to current challenges. These curricula cultivate mainly literacy tools. Knowledge about the natural and social phenomena are the subject of the natural and social sciences. In particular, knowledge, skills and values about the socio-political organisation of the world are the domain of the social sciences.

This chapter analyses the concepts of citizenship and sustainability, refers to the Sustainable Development Goals (SDGs) as defined in a UN conference (Agenda 2030, Seventeen Sustainable Development Goals—SDGs) and presents ways to promote sustainability in education as well as relevant research, with a focus on goals related to the natural environment. We explore the ideological framework; the content and the appropriate methods for a curriculum of citizenship education.

## **2. Citizenship and citizenship education**

*'Education is always a political act… It is impossible to remain neutral in education, all educational policies and practices have social implications'*

*Paulo Freire*

Citizenship is a highly complex concept. Citizenship means being a member of a political community. The members of this political community have the same rights and responsibilities towards the state and other members of the community. Thus, citizenship is a legal status on the one hand, and a social relationship between citizens on the other [4].

The term citizenship implies a relationship, the relationship of the individual with the public life and with the polity. It is the status of a person that makes him/her a citizen, and this is achieved on the one hand empirically as a process of socialisation and education, and on the other hand legally as a status conferred by law. In the

#### *Curriculum for Citizenship and Sustainability DOI: http://dx.doi.org/10.5772/intechopen.103981*

former case, we have a *de facto* acquisition of citizenship, while in the latter we have a *de jure* conferment of political rights on individuals. The de jure procedure for acquiring citizenship varies from country to country, with differences concerning persons who have a first citizenship of another country or are stateless. Such cases are mainly migrant populations or refugees.

In her paper *The Public Self,* Virginia Rettinger describes the way in which the public self is expressed. According to her, the public self is that part of the self which is concerned with political and social issues. To a certain extent, all individuals express this part of themselves. The two forms of being, public and private, are manifested in situations and activities, which are clearly distinct from one another. For the formation of the public self to be achieved, understanding, nurturing and support are necessary. In identifying its main characteristics, Rettinger suggests that the public self:

In its strict sense, citizenship is a legal concept, and it can only be exercised in the context of a state. Citizenship implies a sense of identity, loyalty, and devotion to the idea that the citizen should assume responsibilities for the state, which is the source of the political rights he/she enjoys. Heater claims that instruction in citizenship, as a status and a right, can only be partial and distorted unless it addresses the issue of identity and loyalty ([6], pp. 62–63). It is perceived as an idea or an ideal comprising of five constituent traits. It can be seen that the most clear-cut aspects are those regarding the legal, political and social status of citizenship. *Civil citizenship* is about the protection of civil rights, *political citizenship* is about the relationship between the law and election procedures and *social citizenship* refers to all things related to social welfare and social benefits. The other two aspects of citizenship, *civic virtue* and *identity*, are less tangible. They both refer to the experiential relationship between the citizen and the polity. Civic virtue, being a good citizen, means to behave in a politically moral way towards the state-polity and to your fellow citizens. The quality of civic virtue is based on political identity [6]. Essentially, political identity is free from the restrictions of the nation-state and the exclusive commitment to a unique level of political loyalty.

The concept of *global citizenship* does not relate to nation-states or similar geographical and political entities. Global Citizenship Identity focuses on the development of active and democratic citizens who are characterised by global consciousness, a shared understanding of current humanity issues and a strong interest in providing solutions. UNESCO identifies Global Citizenship as 'a sense of belonging to a broader community and common humanity. It emphasizes political, economic, social and cultural interdependency and interconnectedness between the local, the national and the global' ([7], p. 14).

#### **2.1 Citizenship education**

Citizenship education is a part of the education systems of all modern states. Pedagogues, philosophers, political scientists and sociologists have sought to define the field of citizenship education. There are a number of definitions, each reflecting the respective viewpoint (ideological, theoretical and didactic) and the specific historical circumstances in which each of these attempts was made. This is a strong indication of the inherent dynamics of citizenship education, which has been linked to the construction and operation of the nation state, while today, in the globalisation era, a cosmopolitan approach is being promoted.

Various terms have been used for citizenship education such as *Civic Education*, *Political Education*, *Education for Citizenship*, *Education for Democracy*, *Law-related Education and Values Education*, which can be found in the literature. All of these terms suggest the study of political issues such as political values, democracy, law, rights and responsibilities, peace education, intercultural education and education for sustainable development.

The necessity of citizenship education is set out in the Convention on the Rights of the Child, where Article 29 declares that 'The States Parties agree that the education of the child shall be directed to … (d) the preparation of the child for responsible life in a free society, in the spirit of understanding, peace, tolerance, equality of sexes, and friendship among all peoples, ethnic, national and religious groups and persons of indigenous origin; (e) The development of respect for the natural environment' ([8], p. 9).

The construction of the political identity has its roots in ancient Greek literature, and of certainly distinguished philosophers and pedagogues, such as Rousseau, Dewey, Freire, Giroux, Crick and Reimers, have strongly emphasised the importance of this central aim of education. Dewey stresses that 'Since a democratic society repudiates the principle of external authority, it must find a substitute in voluntary disposition and interest; these can be created only by education. … A democracy is more than a form of government; it is primarily a mode of associated living, of conjoint communicated experience' ([9], p. 87). For Paulo Freire, education is always a political act, and also it is impossible to remain neutral in education, all educational policies and practices have social implications [3]. Therefore, the basic purpose of education is the formation of the autonomous and active citizen. The concept of the active citizen has been interpreted as that of a citizen who 'governs himself and takes responsibility for his actions, thus reducing his dependence on the state' ([10], p. 774) 'to be a citizen is to participate' ([11], p. 85), also, 'It is only when one leaves one's home and enters the public space that the dialogue about a citizen's idiosyncrasy begins' ([12], p. 41). Also, 'Citizenship or civics education is construed to encompass the preparation of young people for their roles and responsibilities as citizens and, in particular, the role of education (through schooling, teaching and learning) in that preparatory process.' ([13], p. 2) and 'Citizenship education cannot stand by itself, independent of cultural norms, political priorities, social expectations, national economic development aspirations, geo-political contexts and historical antecedents' ([14], p. 17).

According to the Council of Europe, 'Education for democratic citizenship means education, training, awareness-raising, information, practices and activities which aim, by equipping learners with knowledge, skills and understanding and developing their attitudes and behaviour, to empower them to exercise and defend their democratic rights and responsibilities in society, to value diversity and to play

#### *Curriculum for Citizenship and Sustainability DOI: http://dx.doi.org/10.5772/intechopen.103981*

an active part in democratic life, with a view to the promotion and protection of democracy and the rule of law' ([15], s.I.1.b).

Crick and Lister have provided a definition of citizenship education encompassing all its main aspects. According to them, the description of the main characteristics of political literacy is crucial and it should precede the formulation of any proposal concerning curriculum frameworks for the subject of Citizenship Education. In their document *Political Literacy, the centrality of the concept*, they attempt a theoretical conflation of political theories with education theory. Three important aspects of citizenship education are noted:

The above definition is principally oriented to the microsystem of each school's educational community, taking into consideration all the factors that may be involved in the developmental process of this school subject. However, schools do not evolve in a vacuum. Rather, they exist and operate within the context of a specific community, a particular political system. Today, a broader approach should be taken to school knowledge for the reason that social identities and cultures are no longer secure and static, 'Social mobility, migration, increased awareness of gender, environmental concerns, social exclusion and class all continue to contribute to a general challenge to traditional verities' ([17], p. 97).

Serious objections have been voiced with regard to ethnocentric curricula. The most notable of these focuses on the discrepancy between the fact that pedagogical work cultivates a humanitarian culture while, at the same time, it promotes views on separate races, and friendly and barbarian peoples [2]. The "political cosmopolitasnism" advocates the world-wide democracy [18]. The merit of political identity lies in creating a sense of belonging, as well as in cooperation, loyalty, stability and social solidarity. The political identity formed in the context of civic nationalism is flexible and, therefore, capable of covering many different political views and of being open to cultural pluralism ([19], pp. 49–64). Thus, since the development of political identity through the education system is necessary, this identity should be based on law, reason and political values. The viewpoint has been expressed that an ethnocentric curriculum is only legitimate as a response to the *nation at risk* theory, which

creates a general impression of the nation-state in economic decline [20]. To provide a brief definition of Citizenship Education, one could say that Citizenship Education is education provided to school-age people which involves the systematic cultivation of political values and the study of social and political institutions, with the ultimate goal of developing autonomous and democratic personalities ([21], pp. 16–26).

Competencies required for democratic life include values, skills, knowledge, critical understanding and attitudes. It is referred to the ability of applying learning outcomes adequately in a defined context, not limited to cognitive elements and encompasses functional aspects and ethical values [22].

Competences need to be practiced, not only taught theoretically. The area of competence is defined as a combination of knowledge, skills and attitudes appropriate to the context. The European Framework on Key Competences for democratic culture, emphasise,

Based on what has been mentioned so far, we can summarise that citizenship education cultivates political values, constructs specific social knowledge and is implemented by democratic teaching strategies. In terms of political values, citizenship education includes universal human values such as democracy, autonomy, equality, freedom, identity, rights, responsibility, justice, respect, tolerance, freedom of speech and the right to be heard.

In recent decades, sustainability has emerged as a contemporary political value, whose meaning does not only concern the protection of the natural environment but extends beyond it, to the coexistence of humans and the environment, to North– South relations and the exhaustion of natural resources, to the emergence of new forms of poverty and racism and to the justice of nature. All this has raised concerns about whether or not humankind has respected the natural environment and its balance, and today, seeing the impasse, views are being expressed regarding the development of justice of nature [24]. The very fact is that all the categories of rights were institutionalised with a man-centred approach. Social, political and human rights were all institutionalised in relation to humans, nature was taken for granted and sustainable, but it seems that it was not.

Citizenship education knowledge focuses on humanity's social achievements, the way of social and political organisation, issues of power, pressure groups, global organisations, polities and contents of social studies. On the basis of the new political value, the value of sustainability, the knowledge content of civic education refers to the interactive relationship between human beings and natural environment and the value of a righteous coexistence that does not unfairly harm any category of people, races and nations, but also natural ecosystems. Such an approach extends the content of citizenship education from the local and national to the global and cosmopolitan environment.

#### *Curriculum for Citizenship and Sustainability DOI: http://dx.doi.org/10.5772/intechopen.103981*

Regarding teaching strategies, citizenship education is understood as a democratic pedagogical praxis, which is developed with actively involved students, where teachers do not consider themselves as the authority of knowledge, as they explore and learn together with students. Teachers have the role of facilitator and orchestrator of pedagogical praxis, while ensuring that pedagogical action takes place in the community and the school operates as a civil society. In order to be able to approach it properly and to teach relevant political issues, educators should receive extensive training in subjects pertaining to the social sciences. Citizenship education should focus more on reality and experience than on knowledge accumulation. As Dubet states, it should cultivate the capacity to learn and not just content knowledge aquisition, and to be directed towards discovering the common ethnic culture, over and over again, in a world that is open and diverse [25].

To sum up, Citizenship Education is characterised by an interest in developing autonomous and democratic personalities in young individuals, awareness of their responsibilities, acknowledgment of their rights, promotion of respect for, tolerance and solidarity to their fellow humans, and compliance with the law and the conventions of the political entity (state or federation) which provides them with citizenship, i.e. with the property which grants them the right to act as political beings in the context of democratic political institutions.

## **3. Sustainability and global citizenship**

*'…the first environmental crisis is the potential collapse of the natural world … the second environmental crisis is the removal of children from the natural world' George Monbi*

In today's rapidly changing global landscape, the individual is called upon to manage with a fresh, flexible and original look his/her private spacetime and the daily change of this. Contemporary challenges humankind has to address are the question of coexistence, staking the survival of the species, new complex problems, e.g., pandemics and environmental pollution. These challenges transcend national borders and lead to the need for global awareness and the identity of global citizenship. Sustainability is emerging as a contemporary political value. It engages every field of the human community, science, politics and society. International organisations have released proposals for sustainable policies, scientists are researching the challenges related to sustainability and education seeks to cultivate values, skills and attitudes for sustainable behaviour in students. Such behaviour is based not only on respect for people but also for ecosystems and nature as a whole. In the undisputed universal human and political values, the value of sustainability is projected as the supreme imperative, which man should not ignore.

Global Citizenship Identity focuses on the development of active and democratic citizens who are characterised by global consciousness, a shared understanding of current humanity issues and a strong interest in providing solutions. UNESCO identifies Global Citizenship as 'a sense of belonging to a broader community and common humanity. It emphasizes political, economic, social and cultural interdependency and interconnectedness between the local, the national and the global' ([7], p. 14). Global citizenship education '…is used as an "umbrella term" covering themes such as education for tolerance and appreciation of diversity, conflict resolution and peace, humanitarian action and introduction to the principles of human rights and humanitarian

law, as well as civic responsibilities,—as these themes relate to local, national and international levels' ([18], p. 9). As regards global orientation of education, aims to empower learners to engage in active roles locally, nationally and globally, to face global challenges and sustainable world.

Comparing the identity of citizenship in the past with this of nowadays, citizens had only the identity of their state whereas today there are many elements that define citizenship and define many identities. This is the right way to construct global citizenship as identity, an identity that defines the relationship to others. Also, rather than being linked to a kind of institutionalisation, the concept of global citizenship refers solely to global citizenship as identity. This makes the concept of global citizenship as an identity more rooted in the realities of international relations than its concept as an institution [26].

Sustainability means enduring into the long-term future; it refers to systems and processes that are able to operate and persist on their own over long periods of time. 'The adjective "sustainable" means "able to continue without interruption" or "able to endure without failing." The word "sustainability" comes from the Latin verb sustinēre, "to maintain, sustain, support, endure", made from the roots sub, "up from below" and tenēre, "to hold" ([27], p. 3).'

Sustainability refers to three dimensions, Environment—Ecological sustainability, Economics—Economic potential and Equity—Social inclusion. These three dimensions—environment, economy and equity—are sometimes called the 'triple bottom line' (TBL), a term introduced in 1997 by corporate responsibility expert John Elkington ([28], pp. 18–22). They are referred to as the 'three E's' and are also known as the three pillars of sustainability or 'planet, people and prosperity' [29]. Sustainability science is a field of study devoted to tackling the challenges of sustainable development in the transition towards sustainability. This field is interdisciplinary, 'defined by the problems it addresses rather than by the disciplines it employs' ([30], p. 26). The concept of sustainability has a dynamic rather than a static meaning, which promotes the continuous cultural and social change for development of global solidarity and justice [31].

UNESCO has encouraged national government agencies, transnational and nongovernmental organisations and teachers and researchers to pursue various policies, programs and pedagogies to foster and further develop global citizenship education. The United Nations in 2015 defined 17 Sustainable Development Goals (SDG) to end poverty, protect the planet and ensure prosperity for all as part of a new sustainable development agenda, and they must be achieved by 2030. According to the UN Secretary-General Ban Ki-moon, the SDGs are a to-do list for people and planet, and a blueprint for success. The goals address the needs of people in both developed and developing countries, emphasising that no one should be left behind. Broad and ambitious in scope, the agenda addresses the three dimensions of sustainable development: social, economic and environmental, as well as important aspects related to peace, justice and effective institutions [29].

Three dimensions occur by the SDGs, ecological sustainability, social and cultural sustainability and economic sustainability. In social and ecological systems, modularity means that groups of parts are strongly connected internally, but only loosely connected to other groups. The parts of a resilient system are connected, although not in a predictable, linear way. When one module fails, others keep functioning and the larger system has a chance to self-organise ([32], p. 121). For example, a local food system is a module that may also be connected with national and global food sources, but when there is a disruption in the larger distribution chain, people in

*Curriculum for Citizenship and Sustainability DOI: http://dx.doi.org/10.5772/intechopen.103981*

the community can keep growing food and are less likely to go hungry. Whether in ecosystems, such as forests or oceans, or in social systems, such as cities or nations, the more diverse a system is and the more variations there are, the better that system will be able to deal with change and stay resilient. Diversity gives system flexibility; it has multiple ways to perform its functions, so the failure of one part does not cause the entire system to crash ([33], p. 355). This definition emphasises the global perspective. It also recognises economic and cultural diversity, in terms of needs as well as in terms of contexts for interpretation and implementation of the goals set out in the report.

#### **4. Curriculum for sustainable development**

The Sustainable Development Goal 4 on Quality Education asks Member States to ensure that all learners acquire values, attitudes and behaviours to promote sustainable development, global citizenship and appreciation of cultural diversity and of culture's contribution to sustainable development [29].

Curriculum refers to the overall process of developing, selecting, promoting and evaluating learning contents [34]. On the basis of this term, education is understood as a mechanism that promotes and organises matters related to knowledge. As far as the subject of Citizenship Education is concerned, it is crucial that educators are free to improvise. A closed curriculum would deprive Citizenship Education of its inherent vitality. In contrast, an open curriculum allows teachers to undertake initiative. However, it should be borne in mind that for an open curriculum to be efficient it is vital that educators receive full scientific training in pedagogy and that they be aware of and familiar with themes of social and political science.

The 3Rs literacy was instrumental, not substantial at its core. Writing, reading and arithmetic are tools for approaching knowledge. The question is what knowledge is being promoted for the education of young people and in what ways is it being promoted? Citizens need tools, but first of all they need knowledge about the world around them, human and natural. What exists in the environment, how societies are constituted, how people function and what is the role of the individual both in relation to social action and to the environment. In contemporary curricula, citizenship education is encountered either as a cross-curricular objective or as a distinct school subject. In the former case, citizenship is thought to be promoted by all subjects and by the educational process as a whole. As a consequence, citizenship education is only mentioned in the curriculum as one of its general principles. In the latter case, it is believed that a cross-curricular objective does not suffice to achieve the specific goals of citizenship education. It is, therefore, necessary to apply specialised instruction and to bring children into contact with appropriately designed material.

Education for Sustainable Development, part and parcel of Target 4.7, empowers learners to take informed decisions and responsible action for environmental integrity, economic viability and just society for present and future generations, while respecting cultural diversity. In Oxfam, the philosophy of global citizenship is implemented through a whole-school approach, which involves everyone from learners themselves to the wider community. In this way, global citizenship education creates a culture of global knowledge about other societies, thus instilling tolerance and emphasising the importance of collective power for responsibility [35].

Democratically-oriented curricula develop knowledge, skills and habits that promote civic values [36, 37]. Designing a curriculum that can lead to the establishment of a global citizenship identity is the desideratum. The traditional curricula, promoting the 3Rs, do not seem to suffice to respond to current challenges. What we need is to seek new ideas that can contribute to sustainable development on multiple levels. According to Reimers, the content of such a curriculum should place emphasis on environmental studies, world history and public health. In addition, educators must address the range of skills that global competency requires [38]. Re-examining literacy is a continuous process emerging from social needs and scientific progress. Welch and Freebody showed that each and every era and society undergoes its own literacy crisis [39].

Educators are the main supporters of citizenship and sustainable development education. Given that democratic citizenship is built both through social interaction and through syllabuses and circulars, and that educators are entrusted with the task of applying and developing the moral, mental and learning objectives of specialised activities, their contribution to building a democratic political identity and global consciousness is invaluable. However, the work they are entrusted with is ambiguous in nature. Educators work in the context of educational institutions, and are, therefore, an essential link in the process of producing and spreading scientific knowledge. Their work, however, is not as easy as it may seem. Phillips stresses that teachers are major role models for others and that, because of this, students' preparation for democratic civic participation is more likely to succeed when the autonomy model endorsed is a democratic one. He stresses that the likelihood of democratic autonomy and participation exists where the processes of analysis, judgement and dialogue are at the core of professional training [40]. Educators develop their educational strategies based on their personal theory and oral competencies. Students, in their effort to construct meaning and learn, are directly influenced by the way in which educators manage orality. The genuine dialogue in learning process is highly valuable ([41], pp. 231–247).

#### **4.1 Natural environment and education**

*'What they do not know, they will not protect, and what they do not protect, they will lose'*

#### *Charles Jordan*

Just as in order for young citizens to tolerate and respect other cultures they need to become acquainted with and interact with individuals of other cultural identities, similarly, in order to understand the wealth of the natural environment they need to become familiar with it and aware of its benefits. Plato in his fundamental work *Politeia* stressed, do not force the children in their lessons, but cultivate them by playing, so that they may rather have their own way as long as each one has the dynamic to be. Jean-Jacques Rousseau, in his work *Émile*, stresses that nature and the immediate environment are the sources of knowledge for the child. For John Dewey, the environment and the child's drive for life take a primary place in the New Education.

Environmental education supports many areas of development. Contact with nature is important for children's development in all areas: physical, emotional, social and cognitive [42]. It enhances cognitive abilities and promotes creativity and problem-solving. Surveys of children in schoolyards found that children engage in more creative forms of play in green spaces ([43], pp. 311–330). Nature play is particularly important for skill development, creativity, problem solving and intellectual development [42]. It also improves nutrition. Children who grow their own food are

#### *Curriculum for Citizenship and Sustainability DOI: http://dx.doi.org/10.5772/intechopen.103981*

more likely to eat fruits and vegetables [44], show higher levels of knowledge about nutrition, and are more likely to continue healthy eating habits ([45], pp. 91–93). It has benefits for the visual sense. More time spent outdoors is associated with reduced myopia rates, especially in children and adolescents [46]. Access to green spaces and even views of greenery enhance calmness, self-control and self-discipline, particularly in girls ([47], pp. 1580–1586).

Mousena and Sidiropoulou investigated the views and attitudes of parents of infants residing in the capital city of Athens regarding the phenomenon of children's removal from the natural environment and the disorder caused by Nature Deficit Disorder ([48], pp. 11–18). The results showed that parents are not sufficiently aware that their children's limited contact with nature causes problems. Mostly they appear surprised at the vision problems. Also, patents adopt in about 10% the view that bad weather conditions should minimise children's playground time. The frequency of teachers' responses is interesting. The most important research finding is that, although in Greece the climate and the natural environment favour outdoor activities, parents of young citizens act restrictively for them.

According to the findings of another research, parents consider environmental protection as a necessary condition for improving the quality of life, and they accept environmental awareness as a particularly important factor in shaping children's character [49]. Also, they acknowledge the contribution of environmental education in kindergartens and consider that they themselves, through their actions, are the ones who help their children to develop environment-friendly attitudes. But there is a discrepancy between parents' words and actions as they state that they do not participate in voluntary tree planting, do not seek out shops that promote recycling programs and do not use public transport. Finally, the research data suggest that although parents believe that raising children's awareness of environmental protection issues should be more of a concern for parents and educators, cooperation between them and teachers on environmental education activities is almost non-existent.

Richard Louv, in his book, *Last Child in the Woods*, describes the cost of human alienation from nature. It is manifested by limited use of the senses, difficulty in paying attention and higher rates of physical and emotional illness. According to him, for the new generation, nature is more of an abstraction than a reality. Increasingly nature is becoming something we watch, consume, wear and ignore. Also, the new age and urban development limits play in nature and combined with a hard-wired culture keeps children confined to the home [50]. The term Nature Deficit Disorder (NDD) does not refer to a developmental disorder, as listed in the International Statistical Classification of Diseases and Related Health Problems (ICD-10) or the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), but to the phenomenon of human withdrawal from nature, which causes various developmental problems in children, such as vision problems, obesity and an unwillingness to take initiatives or risks.

The methods proposed for a kind of teaching that promotes environmental education and addresses the SDGs are characterised by critical thinking, experiential and exploratory learning, a holistic approach and authentic learning situations in open spaces, as well as by the involvement, apart from the teacher, of a team of experts. Such methods include Philosophy for Children, Enquiry-Based Learning, Systems Thinking, Project-based Learning, Mantle of the Expert and Open Spaces for Dialogue and Enquiry methodology [51].

In order to bring schools closer to the concept of citizenship and sustainability, it is necessary to define them as public spaces that aim to reintroduce the idea of critical democracy and community. As Henry Giroux stresses, the best way to conceive of the school is as a 'public space', as the centre of citizenship. By public space we mean a tangible set of learning conditions where people come together to talk, engage in dialogue, share their stories and struggle together in a context of social relations that not only do not weaken but enhance the potential for active participation in the public sphere [52].

Civil society, historically, imposed new themes on ecology, environmental threats, feminism, etc., which were the focus of non-centrally institutionalised debates. The role of civil society proved to be decisive in the public framing of many new issues, which went from being part of alternative and marginal debates to becoming elements of the political discourse. Civil society seems not only to be a second society of dissent and opposition but also to sometimes co-shape political publicity and influence the political system in modern democracies [53].

Making school a civil society forum leads to the constitution of a space and a vision that offers alternative ways of seeing and understanding the student, the educator and the school institution. A forum is a podium and a field for the articulation of ideas and the formulation of problems and requests. A space for negotiation and sharing of aspects and views. Fora give space for active citizenship to participate in collective actions. Democracy has inherent dynamic elements, it is not a commodity that you acquire and rest, but it needs constant vigilance to be maintained. Democracy keeps always a promise 'to come' [54]. A place where children and adults participate in projects of political, economic and cultural importance, really this can be seen as such a forum. We need to understand the power that this space has, that it is a central cell of society. Around the young citizens and around the school institutions, there are many other systems, so we need to understand the power of this space and thus orient ourselves towards its new role.

#### **5. Conclusion**

Citizenship and sustainability are main goals for schooling in the 21st century. The plethora of questions about citizenship education and sustainability were impossible to be answered in this chapter. In this text, we have analysed the concepts of citizenship and sustainability, in the spirit of promoting the sustainable development goals, in order to highlight specific issues of their implementation in the school curriculum and teaching strategies. Citizenship education is a highly dynamic subject, which is of concern to the academic community and to education policymakers in every country and internationally. Citizenship is a subject that refers to the education of people to become citizens, to learn to govern and be governed.

Citizenship education concerns values, democracy, autonomy, peace, equality, freedom, collective action, dialogue, communication, recognition, rights, participation, tolerance and respect, empathy, responsibility, autonomy, cultural pluralism, problem solving, decision making, critical thinking, democratic dialogue, openness, transparency, sharing and publicity.

Education for citizenship is a basic purpose of educational systems, which has been linked to the formation and functioning of the nation state, and as a result, an ideologically ethnocentric curriculum has been promoted. However, in the era of globalisation and the contemporary problems of humanity, which transcend national borders, it follows that citizenship education should have a transnational orientation and a cosmopolitan content.

#### *Curriculum for Citizenship and Sustainability DOI: http://dx.doi.org/10.5772/intechopen.103981*

The sustainable development goals set all the parameters for the functioning of societies with a perspective of continuity, both of the institutional achievements of humanity and of the adequacy of the natural environment. Historically, the acquisition of citizenship has required significant ideas, thoughts, struggles, negotiations and institutionalisation. The political constitution of society and the functioning of democracy is both an achievement and a perpetual goal. These are not taken for granted and conquered at once. It is highly doubtful that they are to be considered as conquests that have been established forever. Democracy is not conquered all at once, as it is not a concrete and immutable form of government, it is a constitution that is based on fundamental political values. Democracy is an ideal constantly imminent, 'to come', as Derrida has pointed out. To safeguard the institutional achievements of humanity, there is no other way than to educate the new generation in democracy and the value of citizenship.

A 4Cs curriculum that could be drawn up to serve this purpose would be one that would provide for the following:

**Civic and Political Values**: The cultivation of civic and political values to be the ideological basis of the program.

**Critical Pedagogy and Social Sciences**: Critical pedagogy as a discipline and social studies is the appropriate conceptual framework for the study and formation of citizenship.

**Civil Society**: From a methodological point of view, the function of the school as a forum of civil society can promote the above-mentioned purpose in a creative, critical and open-minded way. With this pedagogical strategy, there will be no exclusions or divisions between us and the others, between insiders and outsiders, the teacher and the pupils, promoting pedagogy in the community. In such a logic without dualisms, knowledge is co-produced participatively, power is shared and responsibility and autonomy are promoted.

**Competent Professionals**: Initial training and continuing professional development of teachers is essential to ensure that teachers' professional competencies are adequate to meet the demands of building citizenship in students in an increasingly changing and globalised world.


**6. Results**

The number of studies that were included in the review totalled 106. Of these, 39 were reviews, while the other 67 were primary studies. 46 of the studies involved children diagnosed within the autism spectrum. This means that about half the research on interventions for children with communicative disabilities have focused children with ASD. 31 of the studies were included in the report published 2011 while 14 were added in the review done 2012. 20 of the publications were reviews while 27 were primary studies. There were comparatively more primary studies, often of high research quality, to be found in the more recent search (2012). Only publications where the children were clearly described as having ASD were included in this review. There were most probably even more studies of the 106 that included children with ASD since sometimes participants were described according to type and/or severity of disability (such as severe communicative disability), and not diagnose..

#### **6.1. Indirect interventions — Education and guidance to parents**

14 primary studies were found. The evidence is moderately to strong since there are also some studies with a high level of scientific control. Many of the studies were noted as showing high validity with respect to external validity as well as social and ecological validity. In several studies the parents were involved in the evaluation procedure and measures of natural interactions were included.

In general the results of education and guidance to parents and staff are very positive al‐ though this review shows that there seems to be a lack of research when it comes to ed‐ ucation and guidance of staff. Only one study was found where pree-school teachers were educated and guided how to use the PECS-method [32]. The results of the parental interventions indicate that they are effective in that positive results can be seen very quickly with respect to different areas and with comparatively little amount of interven‐ tion. This is also probably one of the reasons behind the trend that parental education seems to be included as a part of the more recently developed intervention programs. In the second literature search in this study more interventions were found that included guidance of parents (for example 31, 63, 74, 75, 81). Several of these interventions includ‐ ed education that was combined with home-visits when the therapist interacted with and trained the child during natural play situations. The parents observed these play activi‐ ties and the therapist's use of behavioural strategies, which were then discussed an prac‐ ticed during the sessions. The results of these comprehensive programs are included in the section of direct interventions below (table 3), but it is important to also recognize the fairly large amount of indirect instruction in these programs.

The results were analysed and grouped primarily according to the formulated search question but also according to the identified areas of intervention and methods being evaluated in the studies. Building on these results, recommendations and a model for early communicative intervention was suggested. These results were documented in a report being published on the website of the Association of Swedish Habilitation directors [53]. A new literature search using the same procedure as described above led to some revision of results and recommen‐

The results that will be shared in this book chapter concerns the studies that specifically involved children on the autism spectrum, which in total involved about half of the studies, or exactly 47 studies. The data from both literature searches was used: 30 studies from the

The number of studies that were included in the review totalled 106. Of these, 39 were reviews, while the other 67 were primary studies. 46 of the studies involved children diagnosed within the autism spectrum. This means that about half the research on interventions for children with communicative disabilities have focused children with ASD. 31 of the studies were included in the report published 2011 while 14 were added in the review done 2012. 20 of the publications were reviews while 27 were primary studies. There were comparatively more primary studies, often of high research quality, to be found in the more recent search (2012). Only publications where the children were clearly described as having ASD were included in this review. There were most probably even more studies of the 106 that included children with ASD since sometimes participants were described according to type and/or severity of

14 primary studies were found. The evidence is moderately to strong since there are also some studies with a high level of scientific control. Many of the studies were noted as showing high validity with respect to external validity as well as social and ecological validity. In several studies the parents were involved in the evaluation procedure and measures of natural

In general the results of education and guidance to parents and staff are very positive al‐ though this review shows that there seems to be a lack of research when it comes to ed‐ ucation and guidance of staff. Only one study was found where pree-school teachers were educated and guided how to use the PECS-method [32]. The results of the parental interventions indicate that they are effective in that positive results can be seen very quickly with respect to different areas and with comparatively little amount of interven‐ tion. This is also probably one of the reasons behind the trend that parental education seems to be included as a part of the more recently developed intervention programs. In the second literature search in this study more interventions were found that included

dations in a new version of the report that was recently published [53].

730 Recent Advances in Autism Spectrum Disorders - Volume I

review published in 2011 and 16 studies from the updated version of 2012.

disability (such as severe communicative disability), and not diagnose..

**6.1. Indirect interventions — Education and guidance to parents**

**6. Results**

interactions were included.

In several studies of the interventions more specifically aimed at parental education, it was seen that the parent's use of responsive strategies increased [54, 58, 60, 61, 62] and some studies showed that interaction between the parent and the child was positively af‐ fected [57, 58, 62, 65]. Some studies report that the development of communication and language in the child seems to be increased when the parents are provided with educa‐ tion and guidance [32, 54, 56, 61, 62, 64]. Several studies have tried to measure parental stress and other family related parameters that are expected to be affected, also out from parental interviews [54, 55, 56, 61, 65]. Most studies failed in proving effects in this re‐ spect, at least on a level of statistical significance. In some studies the researchers specu‐ late that the questionnaires given before and after an intervention seems to fail in catching an effect. In qualitative studies parents report that they can see the problems of the child more clearly after the course and can be more open about the family problems [55]. This means that items related to family issues even might "get worse" comparing questionnaires filled in blindly before-after intervention.

So far very little is known of the long-term effects of indirect intervention. The few studies with this focus show that the effects seem to fade over time. Both clinicians and researchers hypothesize that there probably is a need to do follow-ups and/or provide booster interven‐ tions to maintain the intervention effects over time. There are also indications that the effects of a parental education on the development of the child seems to be further enhanced when the education is complemented with direct intervention to the child.

#### **6.2. Direct interventions — Provision of training of the child**

19 studies were found of which 10 were reviews (1 meta-analysis) and the rest primary studies. The scientific level of evidence varies, but the recently published primary studies being of high quality certainly strengthen evidence in the area of direct communication intervention.

Direct interventions or training of the child has proved to have a positive impact on the development of the child with ASD as is stated in most, but not so sure in all, of the studies in the table. Exactly what is described to be affected differs in different studies, depending on the focus of the study, but to a large extent also on what have been measured in a particular study. It is more common that classical didactic programs report outcomes within the function- or activity-domain, often by the use of measures of intelligence (IQ) or language (different language tests). The child-directed naturalistic interventions more often describe outcomes in terms of activity or participation and use data of communication or interaction from video analyses, parental questionnaires and interviews.

**Author&year Study design Intervention Evidence grading**

Wong & Kwang, 2010 [75] RCT (small groups) Evaluation of Autism 1-2-3-progam Schlosser: 1

ACD

communication

As mentioned in earlier paragraphs generalization and maintenance has been a big issue within the field of communication and language intervention for years. Generally the childfocused interventions show better generalization and maintenance in younger children with ASD [67, 72, 76]. These studies discuss that the use of the inborn motivation of the child and the use of natural context and natural play context make the difference – all according to current theories of development of cognition and communication. Proponents of didactic training hold that the use of learned words and phrases might be a start of a positive social spiral where the child gets more response and is treated differently. Some reviews come to the conclusion that we still do not have enough evidence to tell which type of program is best, didactic or childfocused, but that the important factors seem to be early start and intensity [66, 69]. According to the meta-analysis of six RCT studies of didactic interventions [80] these however fail in reporting better outcomes than the control groups when it comes to cognition, language and adaptive functioning. Generally the children in didactic training programs also were older [68]. Didactic training in its intensive and comprehensive form seems less effective on younger children and children at early communicative levels [77]. The involvement of the parents in recurrent didactic training activities in the home is also questioned in some studies [68]. There are indications of a high degree of stress in these parents and a comparative study showed that parental stress was lowered when the training was done by others and furthermore that the

Evaluation of the effects of "start-kit" of 12 individual sessions teaching parents communicative strategies

Early Communication Intervention for Children with Autism Spectrum Disorders

intervention for young children at risk of

Comparison of RPMT and PECS on spoken

Schlosser: 2 Nordenström: B Golper. I

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733

Nordenström: B Golper. III

Schlosser: 4 Nordenström: C Golper. II

Schlosser: 2 Nordenström: B Golper. III

Vismara et al, 2009 [81] Group study Non-

Yoder & Stone, 2006 [73] Randomized

concurrent multiple baseline design

comparison

**Table 3.** Studies of direct interventions and comprehensive programs

Woods & Wetherby, 2003 [72] Review, clinical report Review of methods of identification and

results with respect to communication development was enhanced [68].

Several recent studies report outcomes from eclectic comprehensive interventions [30, 31, 74]. These programs are built upon current theories of cognitive, communicative and neurophy‐ siological development but also adds knowledge from the behaviourist tradition or rather Applied Behavior Analysis (ABA) in optimizing the learning situation. More concretely this means that these programs are child-focused in that it makes use of the child's motivation and interests and focus the communication between the parent and the child and are often implemented in the home setting, sometimes after some introductory sessions on a clinic. An analysis of the child's communication development forms the decision of what is going to be focused during interaction. Prelinguistic competencies such as imitation, joint attention and

**Table 3.** Studies of direct interventions and comprehensive programs

**Author&year Study design Intervention Evidence grading**

years

understanding and treating autism

Denver Model for toddlers with ASD

and naturalistic language interventions

Review of parent-mediated intervention/

Comparison of effects of 1) intensity and form of intervention 2) intelligence on adaptive behaviour on children with ASD

Comparison of interventions for play and joint attention in children with ASD

intervention to promote communication

interaction in young children in educational

Characterizing and Predicting Outcomes of Communication Delays in Infants and Toddlers: Implications for Clinical Practice.

communication intervention to young

Evaluation of a program aimed at stimulate language learning in disabled children

intervention to children with ASD

joint attention

settings

children with ASD

for children with ASD

training of children with ASD

Schlosser: 4 Nordenström: C Golper. I

Schlosser: 4 Nordenström: C Golper. I

Schlosser: 1 Nordenström: A Golper. III

Schlosser: 4 Nordenström: B Golper. II

Schlosser: 3 Nordenström: B Golper. III

Schlosser: 2 Nordenström: B Golper. II-III

Schlosser: 4 Nordenström: B Golper. II

Schlosser: 1 Nordenström: A Golper: III

Schlosser: 2 Nordenström: A Golper. III

Schlosser: 2 Nordenström: B Golper. III

Schlosser: 4 Nordenström: B Golper. I

Schlosser: 6 Nordenström: C Golper. I

Schlosser: 6 Nordenström: C Golper. I

Schlosser: 5 Nordenström: B Golper. III

Schlosser: 1 Nordenström: A Golper. III

Charman, 2010 [76] Review Review of developmental approaches to

Corsello, 2005 [66] Review Review and discussion of interventions 0-3

Dawson et al, 2010 [30] RCT Study of the effects of : The Early Start

Delprato, 2001 [67] Review Comparison of discrete trial interventions

Goldstein, 2002 [69] Review Review and comparison of communication

Kasari et al (2010) [31] RCT Study of the outcomes of an intervention for

McConkey et al, (2010) [74] Controlled group study Evaluation of the impact of home-based

McConnell, 2002 [71] Review Review of interventions to promote social

Rogers, 2006 [11] Review Review of and historic description of

Spreckley & Boyd, 2009 [80] Meta-analysis Meta-analysis of discrete-trial-interventions

Randomized group

Review Cochrane-report

study

study

expertise

(small groups)

Fernell et al, 2011 [77] Comparative group

732 Recent Advances in Autism Spectrum Disorders - Volume I

Paul & Roth , 2011 [78] Narrative review/

Schuit et al, 2011 [79] Controlled group study

Diggle & McConachie, 2009

Kasari, Paparella & Freeman,

2008 [70]

[68]

As mentioned in earlier paragraphs generalization and maintenance has been a big issue within the field of communication and language intervention for years. Generally the childfocused interventions show better generalization and maintenance in younger children with ASD [67, 72, 76]. These studies discuss that the use of the inborn motivation of the child and the use of natural context and natural play context make the difference – all according to current theories of development of cognition and communication. Proponents of didactic training hold that the use of learned words and phrases might be a start of a positive social spiral where the child gets more response and is treated differently. Some reviews come to the conclusion that we still do not have enough evidence to tell which type of program is best, didactic or childfocused, but that the important factors seem to be early start and intensity [66, 69]. According to the meta-analysis of six RCT studies of didactic interventions [80] these however fail in reporting better outcomes than the control groups when it comes to cognition, language and adaptive functioning. Generally the children in didactic training programs also were older [68]. Didactic training in its intensive and comprehensive form seems less effective on younger children and children at early communicative levels [77]. The involvement of the parents in recurrent didactic training activities in the home is also questioned in some studies [68]. There are indications of a high degree of stress in these parents and a comparative study showed that parental stress was lowered when the training was done by others and furthermore that the results with respect to communication development was enhanced [68].

Several recent studies report outcomes from eclectic comprehensive interventions [30, 31, 74]. These programs are built upon current theories of cognitive, communicative and neurophy‐ siological development but also adds knowledge from the behaviourist tradition or rather Applied Behavior Analysis (ABA) in optimizing the learning situation. More concretely this means that these programs are child-focused in that it makes use of the child's motivation and interests and focus the communication between the parent and the child and are often implemented in the home setting, sometimes after some introductory sessions on a clinic. An analysis of the child's communication development forms the decision of what is going to be focused during interaction. Prelinguistic competencies such as imitation, joint attention and use of symbol play and symbols are seen as basic and pivotal. The behavioural techniques are used to arrange the environment and chose strategies to refine and enhance learning in the natural interaction. The trainer serve as model to the parent and then guide and coach the parent, often in the home.

**Author&year Study design Intervention Evidence grading**

Bopp, Brown & Mirenda, 2004 [83] Review Review of FCT and use of visual

Brady, 2000 [84] Case study Study of the impact of use of SGDs on

Branson & Demcak, 2009 [85] Meta-analysis Evaluation of AAC interventions for

SSRD – Multiple baseline

Millar, Light & Schlosser 2006 [87] Meta-analysis The impact of AAC-interventions on

Papparella & Kasari, 2004 [88] Review Study of the relationship between joint

Schlosser &, 2006 [90] Quantitative review The impact of AAC on children with

Schlosser & Wendt, 2008 [91] Meta-analysis Effects of different types of AAC on

study

Preston & Carter, 2009 [89] Meta-analysis Study of the effects of PECS Schlosser: 1

baseline

Review The impact of AAC-intervention on use

of AAC, symbolic gestures and speech

Early Communication Intervention for Children with Autism Spectrum Disorders

strategies and discussion of the role of speech-language pathologist in working with challenging behaviors

the understanding of speech

toddlers and infants with disability

Impact of PECS on requesting and

Study of the effects of a pictureexhange-intervention using milieu

attention and language – manual

developmental disabilites

speech in children with ASD

with severe communicative disabilities

Evaluation of a program using AAC (not

Review Study of the effectiveness of training of rejecting using AAC

Review Review of AAC-interventions to children

further described)

teaching in the home

speech development

speech

signing

Schlosser: 4 Nordenström: B Golper. II

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735

Schlosser: 4 Nordenström: B Golper. I

Schlosser: 5 Nordenström: C Golper. I

Schlosser: 1 Nordenström: A Golper. III

Schlosser: 2 Nordenström: B Golper. III

Schlosser: 2 Nordenström: B Golper. III

Schlosser: 1 Nordenström: B Golper. I

Schlosser:4 Nordenström: C Golper. I

Nordenström: B Golper. III

Schlosser: 4 Nordenström: B Golper. II

Schlosser: 1 Nordenström: B Golper: II

Schlosser: 4 Nordenström: B Golper. I

Schlosser: 4 Nordenström: B Golper. I

Schlosser: 5 Nordenström: B Golper. II

Binger, Berens, Kent-Walsh &Taylor,

Ganz, Simpson & Corbin-Newsome,

Sigafoos, Drasgow, Reichle, O´Reilly &

Snell, Chen, Lih-Huan & Hoover, 2006

van der Meer et al, 2011 [93] Controlled group

**Table 4.** Studies of education and guidance to parents

Tait, 2004 [92]

[94]

Mancil et al(2009) [95] SSRD – multiple

2008 [82]

2008 [86]

The majority of the primary studies in the table above report excellent outcomes [30, 31 70, 73, 74, 75, 81]. In general the research quality of evaluations of these interventions were high since many were of RCT type or Randomized Group studies. External, social and ecological validity was also considered as generally high partly due to the use of more interactional data and information from the stakeholders. The studies show that these interventions seem to be very effective in proving positive outcomes with respect to interaction, parental communication style and child development. Some of these intervention programs are of comparatively low intensity and short, which is interesting and important, as high intensity traditionally have been said to be essential to success in children with autism

Some articles compare interventions and discuss recommendations with respect to different needs of the child or family. A comparison of the AAC-method PECS and RPMT (a compre‐ henesive program containing parental education in the use of responsive strategies and training of the child and guidance to parents in their home) showed interesting results with respect to communication outcomes in the children [73]. The children at the earliest commu‐ nicative stage, not yet being interested in objects, seem to develop more with RPMT. At the next communicative stage when the children has an interest of objects, an understanding of cause and effect and some emergent understanding of joint attention PECS is more effective. When joint attention is more established the Prelinguistic Mileu Teching strategies (behavioral techniques implemented in natural interaction) in the RPMT seems to be more operant. It was also seen that the PMT-training had better effect for those children whose mothers used a responsive communication style. The focus on development of joint attention is emphasized as the primary goal in this study with a successive introduction of symbol play as joint attention is being established [73].

Finally, one review studies the effect of different types of interventions to promote social interaction in pree-school settings and conclude that there is good evidence that it is important to work both with the child with disability as well as with his/her friends in the school environment [71].

#### **6.3. AAC intervention**

The field of AAC is a fairly new field of knowledge that has gradually grown as there is a increasing interest in functional communication and in ensuring the communicative rights of individuals with disability. There has also been an explosion of available communication technologies and methods that can support and improve communication for individuals with autism. We have probably and hopefully only seen the dawn of these new options. It is also possible to see that we are moving from using one technique or approach at the time to working with multimodal techniques or approaches where different tools and methods combined with an understanding of communication and use of interactional strategies build a total system of communication.

**Table 4.** Studies of education and guidance to parents

use of symbol play and symbols are seen as basic and pivotal. The behavioural techniques are used to arrange the environment and chose strategies to refine and enhance learning in the natural interaction. The trainer serve as model to the parent and then guide and coach the

The majority of the primary studies in the table above report excellent outcomes [30, 31 70, 73, 74, 75, 81]. In general the research quality of evaluations of these interventions were high since many were of RCT type or Randomized Group studies. External, social and ecological validity was also considered as generally high partly due to the use of more interactional data and information from the stakeholders. The studies show that these interventions seem to be very effective in proving positive outcomes with respect to interaction, parental communication style and child development. Some of these intervention programs are of comparatively low intensity and short, which is interesting and important, as high intensity traditionally have

Some articles compare interventions and discuss recommendations with respect to different needs of the child or family. A comparison of the AAC-method PECS and RPMT (a compre‐ henesive program containing parental education in the use of responsive strategies and training of the child and guidance to parents in their home) showed interesting results with respect to communication outcomes in the children [73]. The children at the earliest commu‐ nicative stage, not yet being interested in objects, seem to develop more with RPMT. At the next communicative stage when the children has an interest of objects, an understanding of cause and effect and some emergent understanding of joint attention PECS is more effective. When joint attention is more established the Prelinguistic Mileu Teching strategies (behavioral techniques implemented in natural interaction) in the RPMT seems to be more operant. It was also seen that the PMT-training had better effect for those children whose mothers used a responsive communication style. The focus on development of joint attention is emphasized as the primary goal in this study with a successive introduction of symbol play as joint attention

Finally, one review studies the effect of different types of interventions to promote social interaction in pree-school settings and conclude that there is good evidence that it is important to work both with the child with disability as well as with his/her friends in the school

The field of AAC is a fairly new field of knowledge that has gradually grown as there is a increasing interest in functional communication and in ensuring the communicative rights of individuals with disability. There has also been an explosion of available communication technologies and methods that can support and improve communication for individuals with autism. We have probably and hopefully only seen the dawn of these new options. It is also possible to see that we are moving from using one technique or approach at the time to working with multimodal techniques or approaches where different tools and methods combined with an understanding of communication and use of interactional strategies build a total system of

been said to be essential to success in children with autism

parent, often in the home.

734 Recent Advances in Autism Spectrum Disorders - Volume I

is being established [73].

environment [71].

communication.

**6.3. AAC intervention**

The research base with respect to AAC used by young children with autism has grown in recent years. This research mostly consists of singe-subject-design studies and case studies, with very few controlled group studies being done. On the other hand there are some welldone meta-analyses published that compile results from singe-subject research studies. Due to the difficulties of conducting RCT studies within the field of AAC-intervention the metaanlyses are important and can be seen as the golden standard. In total 14 studies were identified as focusing the use of AAC and of these 10 were reviews or meta-analyses.

**7. Conclusion**

training is low.

might be an important success factor.

**most effective; indirect or direct interventions?"**

The conclusion of this chapter is presented in the form of eight recommendations and of a model for early communication intervention answering the question that was initially formulated in this study: **"A young child with autism and severe communicative disability, living with his/her parents and being placed in a pree-school group: which intervention is**

Early Communication Intervention for Children with Autism Spectrum Disorders

http://dx.doi.org/10.5772/54881

737

**1. A combination of indirect and direct interventions.** There is strong evidence that the combination of education and guidance to the parents and direct child-focused interven‐ tion to the child in a naturalistic context leads to good outcomes with respect to several parameters such as: development of communication and language, interaction between the parent and the child where the parent uses a responsive communication pattern,

**2. Parental education should include knowledge of and training in the use of responsive strategies and behavioural/environmental teaching techniques within the frames of natural interaction in the home.** Several studies show that parents change their commu‐ nicative style after a few education sessions and that this positively affect the interaction pattern with the child and enhance language development in the child. **Guidance or coaching of the parents in natural interactions in the home environment** is included in

most of the recently presented studies and show very good results in short time.

**3. Direct interventions provided to children on early communicative stage should be child-focused and implemented in daily natural interactions. The intervention should focus imitation, joint attention and symbol use** (speech, symbols, manual signs). Didactic intervention is not effective for young children since maintenance and generalization of

**4. Interventions need to be continuous and include follow-ups and possibilities of booster-intervention.** The few long-term follow up-studies all show that interventions (of different type) tend to wear off by time. The recent published studies show that lowintensity interventions also could yield good results. The engagement of the parent also

**5. Children at early communicative stages should be provided with AAC as early as possible.** There is no age-limit or prerequisites that need to met before AAC is introduced. There is strong evidence that AAC decreases challenging behaviour. There is moderate

**6. AAC-intervention should ideally be multimodal.** All modes of AAC are effective. There is some evidence that symbols (specifically combined with speech output) are learned

**7. PECS (Picture Exchange Communication System) is an effective AAC-method for children at early communicative stages.** There is strong evidence that PECS has a positive effect on interaction and behaviour and that functional communication is increased.

to strong evidence that AAC facilitates development of speech.

faster than manual signs and that iconic symbols are learned faster.

In conclusion, meta-analyses and other studies show that AAC-interventions are cost-effective and give fast results and furthermore tend to stimulate speech development [82, 84, 85, 86, 87, 91]. The best results seem to be reached when the social network surrounding a child is given support and resources, to be able to use responsive strategies and provide communication opportunities and direct training using AAC in natural daily interactions. AAC intervention should be started as soon as communication difficulties are displayed or suspected since AAC promotes communication, language and speech. AAC-intervention has also been proved to effectively decrease challenging behaviour [83]. There is today no mode of AAC that is known to be better than any other for young children with autism. Instead multimodal approaches seem to be the most effective [93]. However, graphic AAC seem to be acquired at a faster rate and also easier to generalize to other situations [90]. PECS has been proved to be an effective AAC method, specifically at early stages of communication and with respect to the first three phases of the method [89].

**Figure 1.** Model for early communication intervention


**5. References**

Fig. 12. PCL impingement seen during arthroscopic examination of PCL retaining

by halofuginone. J Biol Chem. 2004; 279:15167-76.

[1] Daumer KM, Khan AU, Steinbeck MJ. Chlorination of pyridinium compounds. Possible

[2] Xavier S, Piek E, Fujii M, Javelaud D, Mauviel A, Flanders KC, Samuni AM, Felici A,

role of hypochlorite, N-chloramines, and chlorine in the oxidation of pyridinoline cross-links of articular cartilage collagen type II during acute inflammation. J Biol

Reiss M, Yarkoni S, Sowers A, Mitchell JB, Roberts AB, Russo A. Amelioration of radiation-induced fibrosis: inhibition of transforming growth factor-beta signaling

prosthesis.

**5. References**

Chem. 2000; 275:34681-92

Arthroscopy Following Total Knee Replacement 255

[42] Ip D, Wu WC, Tsang WL. Comparison of two total knee prosthesis on the incidence of

[43] Anderson MJ, Becker DL, Kieckbusch T. Patellofemoral complications after posterior-

[44] Lucas TS, DeLuca PF, Nazarian DG, et al. Arthroscopic treatment of patellar clunk. Clin

[45] Clarke HD, Fuchs R, Scuderi GR, et al. The influence of femoral component design in

[46] Lonner J, Jasko J, Bezwada H, et al. Incidence of patellar clunk with a modern posterior-

[47] Maloney WJ, Schmidt R, Sculco TP. Femoral component design and patellar clunk

[48] Yau WP, Wong JWK, Chiu KY, Ng TP, Tang WM. Patellar clunk syndrome after posterior stabilized total knee arthroplasty. J Arthroplasty 2003; 18: 1023–8. [49] Larson CM, Lachiewicz PF. Patellofemoral complications with the Insall– Burstein II posterior-stabilized total knee arthroplasty. J Arthroplasty 1999; 14: 288–92. [50] Sringari T, Maheswaran SS. Patellar clunk syndrome in patellofemoral arthroplasty—a

[51] Vernace JV, Rothman RH, Booth RE. Arthroscopic management of the patellar clunk

[52] Ranawat AS, Ranawat CS, Slamin JE, Slamin JE, Dennis DA. Patellar crepitation in the

[53] Diduch. D, Giles. R. The efficacy of arthroscopy following total knee replacement.

[54] Franz Landsiedl, M.D., Nicolas Aigner. A New Arthroscopic Technique for Revision

[55] Dowson D, Taheri S, Wallbridge N. The role of counterface imperfections in the wear of

[56] Hood RW, Wright TM, Burstein AH. Retrieval analysis of total knee prostheses: a

[57] Levesque M, Livingston BJ, Jones WM, Spector M. Scratches on condyles in normal functioning total knee arthroplasty. Trans Orthop Res Soc. 1998;23:247. [58] Howie DW, Vernon-Roberts B. The synovial response to intraarticular cobaltchrome

[59] Mintz L, Tsao AK, McCrae CR, Stulberg SD, Wright T. The arthroscopic evaluation and

P.F.C. sigma total knee system. Orthopedics 2006; 29: S68–70.

syndrome following posterior stabilized total knee arthroplasty. J Arthroplasty

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 13, No 2

of the Posterior Compartment in Symptomatic Total Knee Arthroplasty; Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 21, No 4

method and its application to 48 total condylar prostheses. J Biomed Mater Res.

characteristics of severe polyethylene wear in total knee arthroplasty. Clin Orthop.

stabilized total knee arthroplasty: a comparison of 2 different implant designs. J

the elimination of patellar clunk in posterior-stabilized total knee arthroplasty. J

patella clunk syndrome. Int Orthop 2002;26:48–51.

stabilized knee design. Am J Orthop 2007; 36: 550.

syndrome. Clin Orthop 2003; 410: 199.

case report. Knee 2005; 12: 456–7.

polyethylene. Wear. 1987; 119:277.

wear particles. Clin Orthop. 1988; 232:244-54.

1989;4:179–82

(April), 1997

(April), 2005

1983;17:829-42.

1991; 273:215-22.

Arthroplasty 2002; 17:422–6.

Orthop 1999; 367:226.

Arthroplasty 2006; 21:167.

[22] Kim DH, Gill TJ, Millett PJ: Arthroscopic treatment of the arthrofibrotic knee.

[23] Millett PJ, Williams RJ III, Wickiewicz TL: Open debridement and soft tissue release as a

[24] Beight JL, Yao B, Hozack WJ, et al: The patellar clunk syndrome after posterior

[25] Hozack WJ, Rothman RH, Booth RE, et al: The patellar clunk syndrome: a complication

[26] Diduch DR, Scudeii GR, Scott WN, et al: The efficacy of arthroscopy following total

[27] Insall JN, Lachiewicz F, Burstein AH: The posterior stabilized condylar design. Two to

[28] Thorpe CD, Bocell JR, Tullos HS: Intra-articular fibrous bands patellar complications

[29] Bocell JR, Thorpe CD, Tullos HS: Arthroscopic treatment of symptomative total knee

[30] Lintner DM, Bocell JR, Tullos HS: Arthroscopic treatment of intraarticular fibrous band

[31] Figgie HE, Goldberg VM, Heiple KG, et al: The Influence of tibial-patellofemoral

[32] Insall JN, Salvati E: Patella position in the normal knee joint. Radiology 101:101,

[33] Okamoto T, Fukani H, Atsui K, Fukunishi S, Koezuka A, Maruo S (2002) Sonographic

[34] Scott RD, Volatile TB (1986) 12 years experience with posterior cruciate retaining total

[35] Sculco TP, Martucci EA (2001) Knee arthroplasty, chapter 6. Patellofemoral joint.

[36] Shoji H, Shimozaki E (1996) Patellar clunk syndrome in total knee arthroplasty without

[37] Vertullo CJ, Easley ME, Scott N, Insall JN (2001) Mobile bearings in primary knee

[38] Callaghan JJ, Insall JN, Greenwald AS (2000) Mobile-bearing knee replacement:

[39] Pollock DC, Ammeen DJ, Engh GA. Synovial entrapment: a complication of posteriorstabilized total knee arthroplasty. J Bone Joint Surg 2002; 84A:2174.

[40] Takahashi M, Miyamoto S, Nagano A. Arthroscopic treatment of soft-tissue

[41] Brassard MF, Insall JN, Scuderi GR. Complications of total knee arthroplasty. In: Insall

impingement under the patella after total knee arthroplasty. Arthroscopy 2002;

JN, Scott WN, editors. Surgery of the Knee. 4th ed. New York: Churchill

location on function of the knee in patients with the posterior stabilized condylar

appearance of fibrous nodules in patellar clunk syndrome: a case report. J Orthop

after total knee arthroplasty. A follow-up note. CORR 309:230, 1994

of posterior stabilized total knee arthroplasty. CORR 241:203, 1989

four year clinical experience. J Bone Joint Surg A 64A: 1317, 1982

after total knee replacement. J Bone Joint Surg A 72A:811, 1990

knee prosthesis. J Bone Joint Surg A 68A:1030, 1986

knee arthroplasty. Clin Orthop 205: 100–107

patella resurfacing. J Arthroplasty 11:198–201

arthroplasty. J Am Acad Orthop Surg 9: 335–364 602

concepts and results. J Bone Joint Surg Am 82:1020–1041

Springer, Berlin Heidelberg New York

stabilized total knee arthroplasty. CORR 299:139, 1994

knee replacement. Arthroscopy 13:166, 1997

arthroplasty. CORR 271:125, 1991

salvage procedure for the severely arthrofibrotic knee. *Am J Sports Med* 1999;27:552-

*Arthroscopy* 2004;20(suppl 2): 187-194.

561

1971

18:E20.

Livingstone; 2006. p. 1752–3.

Sci 7:590–593

**12**

*USA*

**Arthroscopic Soft Tissue Releases of the Knee**

Intra-articular fibrosis, which includes a family of disorders such as anterior interval scarring, posterior capsular contracture, a tight lateral retinaculum, as well as arthrofibrosis, may lead to alterations in joint biomechanics and can result in pain. 1, 2, 3 Specific releases for each region of fibrosis, along with characteristic physical examination findings, have been described. Familiarity with the diagnosis and arthroscopic treatment of these disorders

The anterior interval has been defined as the space between the infrapatellar fat pad and patellar tendon anteriorly, and the anterior border of the tibia and transverse meniscal ligament posteriorly.1 Trauma or previous surgery may cause hemorrhage or inflammation of the fat pad (Hoffa's Syndrome), which may be followed by fibrosis. If fibrosis occurs between the fat pad and transverse ligament or anterior tibia, it will lead to dysfunction of the anterior knee structures, such as decreased excursion of the patellar tendon and result in stretching of the surrounding synovial tissue, which may lead to pain or even loss of knee extension. 1 Fibrosis within the anterior interval can exist on a spectrum of severity. Paulos et al. described infrapatellar contracture syndrome, a severe form of anterior interval

Patients with anterior interval scarring complain of anterior knee pain, and frequently describe a sense of fullness within the knee, especially with extension. Physical examination may demonstrate a small flexion contracture, decreased proximal excursion of the patella, as well as a positive Hoffa's test 1. Hoffa's test is performed by placing the thumb at the margin of the infrapatellar fat pad and patellar tendon medially and laterally with the knee flexed at 30o (Figure 1). Pressure is applied with the thumb, and the knee is fully extended.  Patients may also have pain in the fat pad with forceful hyperextension of the knee. The patellar tendon and patella should also be carefully examined to ensure they are not also causes of the

Scarring in the fat pad can be visualized on standard T1- and T2-weighted magnetic resonance imaging (MRI). Low T1- and T2- signal identified on sagittal images coursing from the posterior portion of the fat pad to the anterior surface of the tibia and/or

scarring, with fibrosis of the fat pad and severe limitations in range of motion. 5

transverse meniscal ligament indicates anterior interval scarring.

may lead to improved treatment outcomes in this patient population.

**1. Introduction**

anterior knee pain.

**2. Anterior interval release**

**2.1 History and physical examination**

Michael R. Chen and Jason L. Dragoo

*Stanford University Department of Orthopaedic Surgery,*

[60] Damage to Cobalt-Chromium Surfaces During Arthroscopy of Total Knee Replacements, Raab, G, Christopher, J, The Journal of Bones and Joint Surgery, Vol 83-A · Number 1 · January 2001