Understanding the Social Deficits of Autism: Early Identification and Intervention

1. Understanding the Social Deficits of Autism: Early Identification and Intervention Peter Mundy M.I.N.D. Institute and School of Education PROMISING PATHWAYS CONFERENCE, FGCU Research supported by NIH Grants HD 38052, MH 071273, the Marino Autism Research Institute (MARI) and the Lisa Capps endowment for research on neurodevelopmental disorders and education at the M.I.N.D. Institute.

2. OUTLINE • Early Intervention: • Methods and Principles • Understanding Early Intervention • Cognitive, Motivation & Neurodevelopmental Theory • A Transactional and Discrete Trial Intervention for Joint Attention and Symbolic Play • Connie Kasari, Stephanny Freeman & Tanya Paparella, • SRCD, 2007, Boston, MA., USA

3. Early Intervention • Preschool: 0-months to 5-years • Rogers (2006), Yoder & McDuffie (2006) • Social & Communication Development in Autism Spectrum Disorders, Tony Charman & Wendy Stone (Eds.) • First publications 40 years ago • Wolf, Risley & Mees (1964); Hewett (1965); Lovaas, Berberich, Perloff & Schaffer (1966). • Very few Randomized Control Trials (RCT) • Few large scale or comparative studies • Pharmacological & Alternative Communication

4. Discrete Trial Adult Directed Modeling of behavior Verbal & Physical Prompts Primary contingent reinforcement of successive approximations (shaping) Lovaas (1987) Skill Development Developmental Child attention directed Imitation & shared experience Multimodal social contingent reinforcement of developmentally advanced behaviors (voice tone, affect & gesture) Greenspan & Wiedner (2000) Learning Development Early Intervention Methods Discrete Trial Combined Transactional Developmental Responsive Yoder & McDuffie (2006)

5. Interventions and Learning Theory • Behaviorism (Empiricism) – Discrete Trial • Define and manipulate external stimulus behavior response contingencies • Internal mental processes secondary or unnecessary (e.g. Skinner, 1952) • Cognitive Revolution (Rationalism) - Developmental • Internal mental & motivation processes affect learning • Tolman (1932; Piaget, 1952; Chomsky, 1959) • Pragmatics - Developmental • Social functions provide a foundation for language • Bates et al. (1975), Bruner (1975), Halliday (1975) • Constructivism - Developmental • The self-initiation of action, with time & experience is essential to learning (e.g. Piaget, 1952)

6. MARKERS of AUTISM • Social Behaviors • Social Orienting (e.g. responds to name) • Joint Attention (e.g. spontaneous seeking to share) • Imitation • Cognitive Behaviors • Symbolic Play • Language • Social-Cognition • Motivation & Self-Initiations • Koegel, Carter & Koegel (2003)

7. Interventions Targeting Joint Attention • Developmental-Transactional child-parent intervention (Yoder & Stone, 2006) • Programmatic Child Imitation (Lewy & Dawson,1992) • Milieu Teaching Approach (Kasari, Freeman & Paparella, 2006) • Greenspan & Weidner (2000) • Transactional-Behavioral approach (Christina Whalen & Laura Schriebman, 2001) • Parent based Relationship Development Intervention (RDI, Guttstein & Sheilly, 2001)

8. Understanding Early InterventionWhy Target Joint Attention?

9. MAIN IDEAS • Paying attention to what other people attend to is fundamental to human learning, communication, culture and social competence. • A major developmental domain • A fulcrum for neuro-development • An axis of individual differences • Early Development = Joint Attention • Impairment Contributes to Autism

10. Social Joint Attention Responds to Joint Attention (RJA) (emerges 3-6 months) Initiate Joint Attention – IJA (emerges 6-9 months)

11. Dissociation of Initiating and Responding ** ** ** Lo MA = 8 to 22 months Hi MA = 23 to 39 months INITIATING SHARING OF ATTENTION IS THE PROBLEM Mundy, Sigman & Kasari (1994) also see Leekam (2000), Leekam & Moore (2000)

12. Individual Differences & Autism RJA & IBR at 4 years Language at 19 years Sigman & McGovern (2005) N = 48 Social Symptoms Mundy et al. (1994) N = 30 Social Initiations in Adolescents ESCS IJA at 4-5 years N = 51 Sigman & Ruskin (1999) ADOS IJA at 2 years Penn Interactive Play Scale at 9 N = 95 Lord, Floody, Anderson, & Pickles (2003)

13. Joint Attention, DSM-IV & Diagnosis • Qualitative Impairment in Social Interaction • A lack of spontaneous seeking to share enjoyment, interests or achievements with other people… • Marked impairment in the use of multiple nonverbal behaviors such as eye-eye gaze, facial expressions… • Lack of social emotional reciprocity • Failure to develop age appropriate peer relations • Biological impairment of affective relatedness to others (Kanner, 1944)

14. Social-Cognitive Model(Carpenter, Nagell & Tomasello, 1998) Infants engage in JA when they understand others as intentional agents. 9-12 month developmental shift Brooks and Meltzoff (2005) All types of JA are simply different manifestations of this underlying understanding Does not explain individual differences From Gomez (1998)

15. Illustrations of Individual Differences in IJA-EC r = .32, p < .005 r = .35, p < .005

16. JOINT ATTENTION & MOTIVATION Kasari et al. 1990 Mundy et al. 1992 Venezia et al. 2004 TYPICAL

17. Dissociation of Joint Attention and Attachment • Children with autism display attachment • Attachment and IJA not related in autism or in typical development • IJA motivated by reward value of sharing experience?

18. Self-organization and Social Learning • Infants self-organize social information input via joint attention skills • This facilitates learning in both structured and incidental social learning opportunities • Constructivist developmental account From Baldwin (1995)

19. Joint Attention Improves Processing • 9-month olds process pictures more deeply when a passive partner also attend to the picture versus non-joint attention condition (Striano et al. 2006a,b) • Duration of looking to target rather than frequency of looks during gaze-following predicts language (Brooks & Meltzoff, 2007).

20. Primordial Sharing SituationWerner & Kaplan (1963) Symbol Formation Object Symbolic Development Mother Child Parallel Distributed Processing model of cognition suggests representations reflect “summaries” of experience that elicits Distributed neural processing (e.g. McClelland & Rogers, 2003, Nature).

21. Joint Attention & Interconnectivity(Caplan et al. 1993; Henderson et al. 2004; Mundy, et al. 2000, 2002; Striano et al. 2006) 14-Month EEG Coherence Predicts 18-Month IJA N = 32 Infants With Typical Development 14 Month EEG Activity 18 Month RJA IJA and EEG Coherence predict language development (Mundy, Fox & Card, 2002)

22. An fMRI study of the Experience of Joint Attention (Justin Williams et al. 2005)

23. Why Target IJA? • Cardinal symptom • Motivation & Initiations • Cognitive Development • Related to Symbolic Development • Self-Organizing Properties • Constructivistic Development • Helps the child help themselves to learn

24. Developmental Intervention Sequence Social Cognition Child Focus Constructive MOTIVATION Imitation Joint Attention Symbolic Play Language

25. UCLA RCT on Play and Joint Attention Connie Kasari, Stephanny Freeman & Tanya Paparella SRCD Boston, Massachusetts March 30, 2007

26. Study Design Intervention 3.5 years old Joint Attention Symbolic Play Control Follow up Tests 6-weeks 12-months X N = 20 X X N = 21 X X N = 17 X Pre-Tests X X X Random Assignment Screen for Inclusion • Interventions for 30 minutes daily for 5-6 weeks • 5 minutes of priming skill--ABA discrete trial approach • 20-25 minutes of combined developmental and behavioral play targeting specific skill • Child driven, following child’s interests • Imitation of child and development of routines • Criteria and mastery of skill before moving to next skill • “Control” intervention considered “optimal”--6 hours per day, 5 days per week (Standard ABA program)

27. ASSESSMENTS • Children assessed by independent examiners (pre & post) • Joint attention--ESCS • Symbolic play--Structured Play Assessment • Developmental level--Mullens • Language level--Reynell Developmental Language Scales • 4 year follow up--children on average 8.5 years old • Differential Abilities Scale • PPVT • Expressive One-Word Test • ToM, Imitation, ADOS

28. Frequency of symbolic play types:Mother-child interaction * Active Tx Follow Up Kasari, Freeman, & Paparella, 2006

29. Frequency of symbolic play types:Mother-child interaction * 12 months 6 weeks Active Tx Follow Up Kasari, Paparella, Freeman & Jahromi, submitted

30. Initiated Joint Attention Skills:Composite ESCS & MCX * Active Tx Follow Up

31. Initiates Joint Attention Skills:Composite ESCS & MCX * Active Tx Follow Up

32. Expressive Language:Rate of Change Active Tx Follow Up

33. Expressive Language:Rate of Change * * Active Tx Follow Up Kasari, Paparella, Freeman & Jahromi, submitted

34. 4 year follow upChange in IQ Entry and 12 months--Mullens; 4 years--Developmental Abilities Scale

35. Predictors of OutcomeConnie Kasari, Stephanny Freeman & Tanya Paparella (2007) • Only InitiatingJoint Attention improvement predicts to cognitive and language outcomes at 4 year follow up • Initiating Joint Attention improvement also predicts ADOS improvement

36. Why Initiating Joint Attention • Cardinal Symptom of Autism • Constructivist Development Theory • Individual difference reflect motivation, self-organizing, information processing • Interconnectivity Theory • Promoting IJA promotes cortical interconnectivity which supports symbolic ability and central coherence

37. Pivotal Skill Hypothesis • Change in one or two “pivotal” behaviors may lead to changes in a broad range of problematic behaviors. (Koegel & Frea, 1993) • Is joint attention a pivotal skill? • Change in JA as change in motivation to communicate? • Is JA as a marker of readiness to learn?

38. RJA and Individual Differences in Treatment Response • Bono, Daley & Sigman (2005) • 29 four-year-old children • 6-53 hours intervention per weak (24 hours average) • IJA and RJA predicted 1 year language gain • Intervention intensity did not predict language gain directly • Children with higher RJA showed positive effects of intervention intensity • Joint attention, self -organization and learning

39. IJA and Intervention Response • Yoder & Stone (2005, in press) • Randomized Control Trial • 39 parent child ASD dyads • Hanen Early Language Parent Program or Picture Exchange Communication System (PECS) • Hanen parents learn to read and respond to children’s nonverbal communication and focus of visual attention lead. • PECS parents learn to use pictures to facilitate communication with children. • More IJA in Hanen than PECS (p < .001) if children displayed baseline evidence of IJA (at least 7 bids across two assessments)

40. Joint Attention and Pivotal Response Training • Christina Whalen (Dissertation 2001 with Schriebman) • Small sample • Behavior modification approach to RJA and Pointing • Multiple baseline • Positive effects on JA • Generalization • Collateral changes in social initiations, positive affect and language

41. Corkum and Moore (1998) 60 typical infants Used operant training to improve ability of 8 months olds to display RJA Lewy & Dawson (1992) 20 children with autism vs DS (20) and non-DD children (20) Experimental play sessions where adult behavior followed and was contingent on child led to increase in RJA Interventions with RJA

42. RJA Intervention Paradigm

43. Caregiver-Child Interaction and Development in Autism • Siller & Sigman (2002) • 25 children w/autism • Caregiver behavior similar across groups • Synchronized/”following” in predicts language gains over 10 to 16 years • “Following in” with “undemanding vocalizations” best predictor

44. Relational Development Inventory • Steven Gutstein Rachelle Sheely • Clinically Developed • Focus on Experience Sharing or Joint Attention • Manual Based • Detailed Intervention methods • Detailed Assessment methods • Parent/Family focus • No published research

45. Freeze Game • Teaching Social Orienting/Referencing • Parents try to approach child without response • If they get close enough they take and action (tickle, hat, lift) • Once child begins to track • Parents Freeze • Make face • Turn activity into a game.

46. Phases of RDI • Education • Demonstration • Coaching • Independence • Home work • Generation (Parent) • Co-regulation • Maintenance and modification by child

47. RDI Home Intervention • 15 – 20 hours per week • Low stimulation room with been bag furniture • Reduce Complexity – Increase Predictability • Structured (Parents in Charge Initially) • Use amplified/exaggerated affect • Nonverbal communication especially faces • Less Language • Keep it Interesting • Gradual increase of demands on child

48. RDI Intervention with 34 Children

49. RDI and Symptom Reduction

50. Individual Variability and Predictors of Preschool Language Outcomes in Autism Sally Rogers, Ph.D. M.I.N.D. Institute, Univ. of California- Davis Susan Hepburn, Ph.D. University of Colorado Health Sciences Center