AUTISM: Early Intervention and Brain Development

1. AUTISM: Early Intervention and Brain Development Travis Thompson, PhD Special Education Program University of Minnesota, Minneapolis, MN & Supervising Psychologist Minnesota Early Autism Project Maple Grove, MN Department of Psychology Minnesota State University Moorhead November 4, 2009

2. MAJOR AUTISM SUB-TYPES Complex autism have subtle dysmorphia have lower IQs (P=0.006), more seizures (P=0.0008), more abnormal EEGs (46% vs. 30%), more brain abnormalities by MRI (28% vs. 13%). all identifable syndromes were in the complex group. Essential autism higher IQs (P=0.02) fewer seizures (P=0.0008) higher sibling recurrence more relatives with autism (20% vs. 9%) higher male to female ratio (6.5:1 vs. 3.2:1). more regressive onset (43% vs. 23%, P=0.02). Miles, J.H.,et.al..(2005) Essential versus complex autism: definition of fundamental prognostic subtypes. Am J Med Genet A. 1;135(2):171-80

3. Implications of Sub-Types • Autism Subtypes Have Major Implications for Understanding Effects of Early Intervention, to Which We Will Return Later….

4. Brain Dysfunction & Autism Symptoms • In Essential Autism there are differences in brain function in 5-6 areas, while most of the brain appears to function normally. • In Complex Autism there appears to be wide-spread differences in brain function typical of individuals with global developmental disabilities.

5. Face Processing & Gaze-Fixation in Essential Autism • Deficits in attention, learning & discrimination of human faces, (Osterling, Dawson & Munson, 2002; Joseph & Tager-Flusberg, 1997). • Disproportionate attention to the mouth versus eyes, (Klin et al., 2002; Schultz et al., 2002). • Tendency not to show the face inversion effect, (Hobson, Ouston & Lee, 1998). • More detailed, less specialize rather than a more specialized configural process, (Joseph & Tanaka, 2003).

6. Amygdala is involved in Gaze Fixation & Facial Emotions • Amygdala damage impairs recognition of emotional facial expressions • Amygdala damage produces diminished eye-fixation • fMRI: Amygdala is activated by emotional facial expressions • esp. eyes, but not among many individuals with autism

7. Social brain function in autismSimon Baron-Cohen et al (1999)European Journal of Neuroscience Assigning mental states to eyes-only facial stimuli usually activates amygdala, cingulate and frontal brain regions, but NOT among Individuals with high functioning ASDs

8. Abnormal amygdala response to fearful facesin people with Asperger’s syndromeChris Ashwin et al (2002) Experimental stimuli: Faces expressing variable intensities of fear Random Neutral 25% Fear 100% Fear Normal amygdala activation Attenuated amygdala activation in autism Attenuated orbitofrontal activation in autism

9. Neuroanatomy of Face Perception: The Fusiform Face Area (FFA) (Courtesy of Bob Schultz, PhD, Yale Univ)

10. Are These Deficits Remediable? • It Appears It May be Possible to OvercomeSome of These Deficits by Promoting New Brain Connections through Early Intervention ….i.e synpatogenesis

11. Synapse Formation As a Function of Age Huttenlocher & Courten (1987)

12. Though Neuroplasticity Peaks Between 10-18 months of Age It Occurs Throughout Our LivesThank Goodness!!But the MAGNITUDE of Gains Appears Smaller & Effort to PRODUCE thoseGains Appear to Be MuchGreater in Later Life

13. Continuum of Therapy Strategies DISCRETE TRIAL INCIDENTAL THERAPY • Highly Structured • Therapist Paced • Therapist Initiated • Massed Opportunities • Therapist/child at table • Therapist selected stimuli • Generalization programmed across stimuli, therapists and sessions • Loosely Structured • *Paced Around Child’s Interests/Activities • Child Initiated • Distributed Teaching Opportunities • Therapist/child in variety of natural settings • Child identified stimuli/materials • Naturalistic reinforcers • Generalization inherent to teaching approach

14. Assessment & Intervention Planning: Assessment of Basic Language & Learning Skills (ABLLS) 25 Scales Categorized Into: Communication & Social Behavior Academic Skills Development Self-Help Skills Motor Skills Each Sub-Scale Broken Into From 6-52 Teachable Component Skills James Partington’s (2007) The Assessment of Basic Language and Learning Skills-R Pleasant Hill, CA: Behavior Analysts, Inc.

15. ABBLS-R is used to Track Changes Over Time Blue= Baseliine Red=Six Months Assessment Vertical= New Sub Skills Horizontal= Degree of Indepedence Within a Sub-Skill Assessment of Basic Language and Learning Skills

16. When Does a Discrete Trial Approach Make Sense? • Teaching difficult-to-learn skills/concepts • Working with a child who has: - a short attention span -challenging behaviors -significant cognitive delay • Natural environment is too distracting

17. When Does a More Naturalistic Teaching Approach Make Sense? • When skills can be embedded within normal daily routines/activities • When initial skills have already been acquired (e.g. using a Discrete Trial approach) • When the therapist can recognize teachable opportunities...a tall order!

18. Meet Blake... Current Age: 6 yrs, 6 mos. Family: Mom, Dad, 16 yr-old sister Diagnosis: Autistic Disorder

19. Initial Diagnostic Profile

20. Theme-based Naturalistic (Incidental) Behavior Therapy • Incorporate principles of applied behavior analysis into theme-based activity units to teach specific skills.

21. Theme-based Naturalistic Behavior Therapy • Theme-based activities • Offer generalization opportunities at school, with his family, and in the community • Incorporate content/activities/structure already familiar to peers during peer play sessions

22. Blake’s Themes • Primary • Restaurant • Doctor • School • Pirates • Secondary • Firefighter • Police officer • Zoo • Farm • Seasonal • Birthday • Holidays • Seasons

23. Theme-based Activities • Picture book • Art/craft activity (e.g, make menus, signs, X-rays, treasure maps, books, cards)

24. Theme-based Activities • Imaginative/pretend play • Waiter, customer • Doctor, patient • Teacher, student • Pirates

25. Parental Input... • Actively collaborate on intervention objectives, programming, measures • Obtain Materials • Observe Sessions • Participate in Clinical Meetings

26. Parental Participation… • Provide generalization opportunities

27. Treatment Acceptability • Parent completed modified Treatment Acceptability Rating Form (TARF) • Endorsed treatment as: -fitting well into family routine -very effective for her child -very likely to make permanent improvements in child’s social/play behavior -would be very interested in participating in similar treatment techniques

28. That’s Interesting, But Is It Effective?

29. THANKS TO…BLAKE AND HIS PARENTSLISA BARSNESS, MA, CLINIC DIRECTORPATTI DROPIK, MA, SLP, SR. BEHAVIOR THERAPISTANDMINNESOTA EARLY AUTISM BEHAVIOR THERAPY STAFF…

30. Why Do Some Children Do Very Well Within 12-18 Months and Some (30-40%) Profit Much Less From the Same Intensity and Longer Duration of IEBT? Sallows and Graupner (2005) Am J Ment Retard. 110(6):417-38.

31. Predictors of Response to TreatmentAmong Rapid Learners • The best single predictorof improvement was motor or verbal imitation at baseline, with a correlation of .90 with ADI-R Social Scale improvement scores. • Motor imitation is mediated by the Mirror Neuron brain system. There is evidence of mirror neuron dysfunctionality in ASDs.

32. Social Predictors of Response to Treatment • ADI-R Low Social Interest, Unresponsiveness to Other’s Approach, Lack of Shared Attention and baseline IQ yielded a negative multiple correlation with Post-Test IQ of .83. • These skills require intact amydgala, cingulate and orbitofrontal cortical function. • These differences appear to be present in the first year of life (Zwaigenbaum et. al) suggesting that typical early parenting has been insufficient to overcome these deficits.

33. Rapid & Slow Learners • The Rapid Learners appear to be a heritable subtype similar to Miles et.al. (2005) Essential Autism • The Slow Learners are a different subtype (Complex Autism) who may have damage to some of the same brain structures due to a different mechanism. They are not influenced by environmental factors to the same degree.

34. These and Other Data Indicate Approximately Half of Children with ASD Receiving IEBT End Up Being Successfully Integrated in Elementary School Residual Characteristics Residual Effects in “Rapid Learners” With ASD Include 36% with Social Anxiety & Inattention Features & 36% With Limited Communication & Social Skills. 9% Were Seen as Isolated and Not Well Liked; However, they Functioned Sufficiently Well to be Integrated in General Education Elementary Classrooms Sallows, G. and Graupner, T. L. (2005)

35. Quality & Intensity • Early Intervention methods that specifically enlist activity in brain structures that are dysfunctional are more likely to produce lasting effects. The qualitative features of intervention matter. Not all interventions are equally effective. • Intensity is very likely critical to outcome, depending on the subtype, as recently cogently argued by Warren, Fey and Yoder (2007)

36. Interaction Between Degree of ASD Disability & Intervention Intensity Autistic Disorder Asp Dis PDD-NOS Autism Severity NVLD Broad Autism Phntype Typical Functioning Reg Ed + Speech Therapy 30+ Hrs IEBT Typical Family + Reg Ed SpEd + Speech Therapy 15-29 Hrs IEBT or PRT Intervention Intensity

37. Conclusions • Autism symptoms are correlated with specific brain dysfunctions, yielding subtypes varying in severity of expression • There appears to be an interaction between severity of the autism subtype and experiential factors influencing its expression • Intensive early behavioral intervention can overcome core autism symptoms of approximately half of children with autism, those with Essential Autism. • It appears these effects are mediated by promoting synaptogenesis • Much more work is needed to identify underlying mechanisms responsible for deficits in slow learners (Complex Autism) so those needs can be addressed more effectively.

38. Paul H. Brookes Publishing Co.

39. Thank You For Your Attention • Travis Thompson • thomp199@umn.edu • travisthompson2@comcast.net • tthompson@meapkids.org • http://travis-thompson.net