Patricia Towle, Ph.D. Westchester Institute for Human Development

1. Early Identification of Infants and Toddlers With Autism and Other Developmental DisabilitiesJanuary 2012Albany, New York Autism Spectrum Disorders in Young Children: The Background, the Basics, and the Behaviors Patricia Towle, Ph.D. Westchester Institute for Human Development

2. The Background • Current prevalence estimates • Current push for early identification • The validity of early identification/diagnoses • How early can we recognize or diagnose?

3. The Background • Current prevalence estimates • 1/150 children • 3-4 boys for every girl • this includes the broad spectrum from severe to mild • Source: CDC--Morbidity and Mortality Weekly • Dec 12, 2009

4. The Background • Push for early intervention • Early intervention works! • The earlier, the better • The closer to 2 years, the • better

5. Early detection: Why is it so important? • Early intervention works! • Supports development ->better foundation-> supports higher levels of independence later • Starts caregivers with their advocacy training-the sooner, the better • Understanding needs, learning the system, accessing resources, impacting on the system • Pediatrician, family medicine and primary care provider in key role to refer parents for evaluations as early as possible

6. The Background • Are early diagnoses reliable and valid?

7. Author, Date Goal Subjects Followed From – To Results Cox, 1999 Predictive validity of ADI-R 45 Compared different ASD risk levels 20 mos – 42 mos Diagnosis of ASD at 20 months is predicted to be highly sensitive and stable Stone, 1999 Diagnostic stability in children under 3 years 25 Aut, 12 PDD-NOS 31.4 mos – 45.0 mos Stability seen in 92+% Szatmari, 2000 Comparison of outcomes between Aut and Asp 46 Aut 20 Asp 4-6 years – 6-8 years Diagnosis of Aut and Asp remained stable Michelotti, 2002 Follow-up of children with ASD-like symptoms 18 with language delay and Aut features 4 years 4 mos – 8 years 7 mos All were diagnosed with an ASD (Aut, Atyp Aut, Atyp Aut with lang. delay) Summary of studies…

8. Author, Date Goal Subjects Followed From – To Results Moore, 2003 Diagnostic stability 16 Aut 3 Atyp Aut 1 Lang disorder 2 years 10 mos – 4 years 5 mos All diagnosed with Aut or Atyp Aut retained ASD diagnosis Freeman, 2003 Diagnostic stability 59 ASD 2-5 years – 4-6 years Early ASD diagnosis remained stable Eaves, 2004 Diagnostic stability 49 with characteristics of Aut 2 years 9 mos – 4 years 11 mos 97% Aut retained ASD 77% PDD-NOS retained ASD Charman, 2005 Diagnostic stability 29 with Aut 2 years – 7 years Standard measures at age 2 years did not predict outcomes at 7 years, but measures at age 3 years were predictive McGovern, 2005 Diagnostic stability 48 with Aut 3 years 11 mo – 19 years 96% retained diagnosis through adolescence/early adulthood Summary of studies cont…

9. The Background Yes, early diagnoses are reliable and valid. • 80-90% of children id’d as toddlers or preschoolers remain on “the spectrum” into school age years • Many young children who have symptoms within the profile of ASD but don’t meet full criteria also end up with an ASD diagnosis • Young children with milder presentations are slightly more likely to change diagnosis from early to later

10. The Background How early is early identification? 3 years – no problem (except for especially mild and complex cases) 24 months– most can be dxed by now 18 - 20 months– many can be 14-15 months – for some, strong risk can be established 12 months – for a few, strong risk can be established

11. There are different developmental trajectories of ASD symptoms in children Three major patterns of symptom emergence: • Different from the start (never really develop social linguistic skills) • Plateau and fade (13 – 15 months) • More clear regression (15-20 months, 20-35 %) in second year • Patterns in between

12. The Basics • Current Terminology • A Spectrum Disorder: The Issues • The Diagnostic Criteria • What Autism Isn’t

13. The Basics Current Terminology The Confusing Array : Pervasive Developmental Disorder PDD Infantile Autism PDD-NOS Asperger syndrome CDD Autism Spectrum Disorder Atypical Autism

14. The Basics Current Terminology Professional Vs. Diagnostic Autism Spectrum Disorder The Pervasive Developmental Disorders

15. The Basics Current Terminology Manual for diagnosing all mental health and developmental disorders in childhood and adulthood Diagnostic and Statistical Manual of Mental Disorders

16. The Basics The Pervasive Developmental Disorders Childhood Disintegrative Disorder Autistic Disorder Asperger Syndrome Rett Syndrome PDD-NOS

17. The Basics The Pervasive Developmental Disorders Autistic Disorder Asperger Syndrome PDD-NOS “Core Disorder” Approx 50% of PDDs- wide range of IQ 15% have some identifiable genetic disorder, for example FraX 30% have seizure disorder Aspergers - social problems without the same degree of language problems Most have average to above average IQ Milder version “Subthreshold”

18. The Basics The issues with a “Spectrum Disorder” 1. A continuum of Severity The Pervasive Developmental Disorders Asperger Syndrome Autistic Disorder PDD-NOS More severe MoreMild

19. The Basics The issues with a “Spectrum Disorder” 2. The interface with cognitive delay The Pervasive Developmental Disorders Asperger Syndrome Autistic Disorder PDD-NOS More severe More Mild

20. The Basics 2. The interface of symptom severity with cognitive delay High Low High Cognitive Functioning Symptom Severity Low

21. High Very Mild Autism/ PDD-NOS/ Aspergers High Functioning Autism Low High Cognitive Functioning Symptom Severity Low Functioning Autism ID (MR) with Autistic-like features Low

22. The Basics The issues with a “Spectrum Disorder” 3. Variable symptom presentation The Pervasive Developmental Disorders Asperger Syndrome Autistic Disorder PDD-NOS More severe More Mild

23. The Basics Autism Spectrum Disorder:The Three Symptom Domains Social Interaction Communication Repetitive Behaviors

24. The Basics ASD Profile of Behaviors The Three DSM-IV Symptom Domains

25. The issues with a “Spectrum Disorder” Three Symptom Domains: Children can have different degrees of symptoms across them Social Interaction Communication Repetitive Bhvrs mild severe severe mild mild severe

26. The issues with a “Spectrum Disorder” AUTISM SPECTRUM DISORDER Communication Repetitive Behaviors Social Interaction social language difficulties Restricted, repetitive play underdeveloped for age Difficulties initiating and maintaining social interaction Core Features

27. 3. Variable symptom presentation AUTISM SPECTRUM DISORDER Social Interaction Communication Core Features: The environmental factor-- They may be better with highly familiar people in very familiar routines or favorite activities Great unevenness across people and settings is a feature of ASD

28. The Behaviors • Social Interaction • Communication • Repetitive Behaviors

29. Social Interaction Behaviors What are the COMPONENTS? 1. Social Interest: How does a child show that they are interested in and “tuned in” to other people? 2. Emotional Expression or Signaling: How does a child share emotions and how “readable” are they? 3. Capacity for Interaction: How much “back and forth” can they do?

30. The Social Interest Component: How do they show they are interested in and tuned in to others? Seeks Proximity: How “In the Mix” is the child? Seeks Proximity: vs. Indifference or Avoidance Stays physically close if comfortable

31. Seeks Proximity: How “In the Mix” is the child? The Social Interest Component Indifference or Avoidance Stays with others but does not interact Off by himself; may take off when others come near

32. The Social Interest Component Eye Contact1: Gives frequent eye contact Typical eye contact use vs. Avoidance of, reduced, or impersonal eye contact

33. The Social Interest Component Eye Contact2:Monitors partner’s eyes & face for reactions Monitors eyes and face vs. Does not monitor of others

34. The Social Interest Component Eye Contact2:Monitors partner’s eyes for reactions

35. The Social Interest Component Social Initiation: How does the child “get something going” with another person?

36. Social Initiation

37. The Social Interest Component Social Responding: How does the child react to social bids from another person?

38. The Social Interest Component Social Responding

39. The Social Interest Component Social Responding

40. Social Interaction Behaviors What are the COMPONENTS? 1. Social Interest: How does a child show that they are interested in and “tuned in” to other people? 2. Emotional Expression or Signaling: How does a child share emotions and how “readable” are they? 3. Capacity for Interaction: How much “back and forth” can they do?