Conflict of Interest

1. When you see tell tale signs of autism: Early Identification and Intervention Dr. Deepali MankadDevelopmental Paediatrician, The Scarborough-Rouge HospitalJordana CarusoOccupational Therapist, The Scarborough-Rouge Hospital

2. Conflict of Interest • No conflict of Interest • No funding or grant received

3. Objectives • Discuss the differences between DSM-IV and DSM-5 • Early intervention- research and impact • Toddler behaviors that may be tell-tale • Role of primary caregivers • Resources for professionals and families working with children with autism

4. DSM criteria

5. DSM IV vs DSM 5

6. Early Intervention – Impact and Research

7. Early Intervention • Hanen Program- More than words, Talkability • Developmental, Individual Difference, Relationship based model (DIR)- Greenspan Model • Early Start Denver Model-ESDM • Therapy mediated • Social ABCs • Caregiver mediated

8. ESDM • Dawson G et al, 2010 • RCT to evaluate efficacy • Forty-eight children 18-30 m old with ASD • 2 groups, ESDM (developmental and applied behavioural analytic principles) or community intervention • Significant improvements in IQ, adaptive behavior, and autism symptoms

9. ESDM-Brain activity • Dawson G et al, 2012 • Forty-eight 18-30 m old randomized • ESDM vs Community based intervention • After 2 years of intervention EEG activity was measured • Age matched typical children also assessed • ESDM and typical group showed • Increase cortical activity when shown faces in typical children and ESDM group

10. ESDM- Follow-Up study in 6-year-olds • Estes. A et al, 2015 • 39 children followed prospectively • 18-30 months early participation • Intensive 2 year in-home therapy • Followed at 6 years of age, 2 years after intervention ended • Compared to children who received community-intervention • No group differences in the core autism symptoms immediately after but were present 2 years later • No differences in intellectual functioning

11. ESDM-Parent Intervention • Rogers. S et al, 2012 • To examine efficacy of a 12m low-intensity parent delivered intervention for toddlers 14-24m • RCT, 98 children • P-ESDM • No effect • Parent implemented not as effective as intensive intervention

12. Social ABCs • Brian et al 2017 • RCT • 63 parent-toddler dyads, 16-30 m • Confirmed or suspected ASD • Increase in parent smiling predicted increase in child smiling and social orienting • ‘Enabling model’

13. Social ABCs Ongoing projects • Behavioural Intervention • Social ABCs Training for Early Childhood Educators at Humber College • Social ABCs for Toddlers with Suspected Autism: Evaluation of a Parent-Mediated Intervention

14. Early Identification is key!

15. Tell Tale Signs https://www.cdc.gov/ncbddd/actearly/pdf/parents_pdfs/milestonemomentseng508.pdf

16. Social Communication and Behaviours

17. Communication & Social skills Behaviors Difficulty with transitions Need for sameness Repetitive play/interests Insists on certain routines and rituals ‘my way or high way’ Frequent and Prolonged temper tantrums Motor mannerisms • Lack of attention • own name • comments • instructions • interactions • Language delay/difficulty using language skills for functional communication • Social Behaviour • inconsistent eye contact • difficulty with shift of gaze • initiating social overture/play • sharing, turn taking is hard • atypical social skills eg overfriendly with strangers, personal space

18. Motor and Sensory

19. Sensory • Sensory seeking – jumping, spinning, touching, crashing, throwing • Sensory defensive- bothered by loud noise, movement, tactile, • Motor • Oral motor difficulties – difficulty with solid food, speech production, gagging, swallowing • Toe walking • Motor planning • Motor mannerisms • Low muscle tone • Feeding • Texture specificity- sensory related • Selectivity- behavioural • Chewing, swallowing – motor related • Self Regulation • Emotional distress • Self injury and aggressiveness • Atypical arousal

20. Role of Primary Care Physicians Recommend Refer Developmental assessments through Child Development Programs (e.g. SRH, HBKR) Central East LHIN (OT,PT) Early Abilities • Early intervention (Centennial Infant and Child Centre, HBKR Nursery schools) • Gross Motor Programming in the community • EarlyON

22. Does one need a specialist to diagnose children with suspected autism?

23. Educational Resources • https://autisminternetmodules.org/ • http://www.mychildwithoutlimits.org/understand/autism/ • https://www.autismspeaks.ca/

24. Educational…. • ECHO Ontario Autism Program • Ability to screen, diagnose, and manage children and youth with autism spectrum disorder (ASD) in Ontario • The Extension of Community Healthcare Outcomes(ECHO) model • Erase barriers between specialty and primary care • Participate in biweekly teleECHO clinics didactics, mentoring, patient case discussions • ECHO program registration is open

25. Conclusion • Early identification is the way to go! • Primary care physicians play a crucial role!

26. References ESDM • Dawson, G., Rogers, S., Munson, J., Smith, M., Jamie, W., Greenson, J., et al. Randomized controlled trial of the Early Start Denver Model: A developmental behavioral intervention for toddlers with autism: Effects on IQ, adaptive behavior, and autism diagnosis. Pediatrics. 2010. doi/10.1542/peds.2009-0958. • Rogers, S.J., Estes, A., Lord, C., Vismara, L., Winter, J., Fitzpatrick, A., Guo, M., & Dawson, G. Effects of a brief early start denver model (ESDM)-based parent intervention on toddlers at risk for autism spectrum disorders: A randomized controlled trial. J of the Am Acad of Child & Adolescent Psychiatry. 2012;51(10), 1052-1065. • Dawson, G., Jones, E.J.H., Merkle, K., Venema, K., Lowy, R., Faja, S., Kamara, D., Murias, M., Greenson, J., Winter, J., Smith, M., Rogers, S.J., & Webb, S.J. Early behavioral intervention is associated with normalized brain activity in young children with autism. J of the Am Acad of Child and Adolescent Psychiatry. 2012;51(11), 1150-1159. • Estes, A., Munson, J., Rogers, S.J., Greenson, J., Winter, J., & Dawson, G. Long-term outcomes of early intervention in 6-year-old children with autism spectrum disorder.  J of Autism and Developmental Disabilities. 2015;54(7), 580-587. Social ABCs • Brian JA, Smith IM, Zwaigenbaum L, Bryson SE. (2017). Cross-site randomized control trial of the Social ABCs caregiver-mediated intervention for toddlers with autism spectrum disorder. Autism Research (June 2). Epub ahead of print. • L.R. Sacrey, S. Bryson, L. Zwaigenbaum, JA. Brian, I.M. Smith, W. Roberts, P. Szatmari, T.Vaillancourt,C. Roncadin, and N.Garon. (2016). The Autism Parent Screen for Infants: Predicting Risk of ASD based on Parent-Reported Behaviour Observed at 6 to 24 months of Age.Autism (Dec.21). • Brian J, Bernardi K, Dowds E, Easterbrook R, MacWilliam S, Bryson S. (2017). Feasibility of Training Early Childhood Educators in a Community Child Care Setting Using a Caregiver-mediated intervention for toddlers with Autism Spectrum Disorder. Journal of Education and Training Studies (May). 5(5): 93-102.

27. Thank you!