Early Signs of Autism and Assessment in Identification of Autism Spectrum Disorders (ASD)

1. Early Signs of Autism and Assessment in Identification of Autism Spectrum Disorders (ASD) Ann Levine, Psy.D. Neuropsychologist Texas Child Study Center Clinical Director of SHARE ASLevine@seton.org

2. Nuts and Bolts • Early signs of Autism Spectrum Disorders • Gold Standards for Assessment • Neuropspychological Assessment

3. Autism as a Culture • “Autism is of course not truly a culture; it is a developmental disability caused by neurological dysfunction. Autism too, however, affects the ways that individuals eat, dress, work, spend leisure time, understand their world, communicate, etc. Thus, in a sense, autism functions as a culture, in that it yields characteristic and predictable patterns of behavior in individuals with this condition…” • Gary Mesibov, Ph.D.

4. Why Talk about this?Why does it matter • Rates of ASD are increasing • Early intervention has been shown to improve outcomes for children with ASD* • In order for children with ASD to receive intervention, first they need to be identified • To care for a person with autism without early intervention over his/her lifetime the estimated cost is $3.2 million.** *Dawson, G. & Osterling, J.(1997). Early intervetnion in autism. In M.J. Guralnick (Ed.) The effectiveness of early intervention (pp. 307-326).Baltimore: Paul H. Brookes Publishing Co. **Ganx, M., “The Costs of Autism,” Understanding Autism: From Basic Neuroscience to Treatment,S. Moldin, J.L.R. Rubenstein, eds., CRC Press, 2006, pg. 475-502. (As reported in the California Legislative Blue Ribbon Commission on Autism Report, Sept. 2007: An Opportunity to Achieve Real Change for California with Autism Spectrum Disorders.)

5. Typical development

6. Atypical Development

7. Autism Spectrum DisordersASD • Early emerging neuro-developmental disorders that have an impact on most domains of cognitive and adaptive functioning. • Developmental disorder involving life-long impairments in social interaction, communication, and narrow interests/repetitive behaviors

8. What is needed • Coherent picture of early behavioral profiles and developmental trajectories that help distinguish very young children with ASD from typical developing children and from children with other developmental delays.

9. History of Determining Early Signs of ASD • Retrospective studies • Limitations include • Recall bias • Possibility of isolated case reports representing atypical or most severe cases

10. Currently Determining Early Signs of ASD • Prospective studies: • following infants that are at risk of developing ASD • Provides an opportunity to more accurately characterize the development of regression in ASD

11. Possible Areas of Dysfunction in the 1st Year • 0-3 months • Preference for face like stimuli • Sensitivity to speech like sound • 3-6 months • Development of social interactions with others • 6-9 months • Response to name • Social games (peek-a-boo) • Recognize identity, affect, gender with face processing • 9-12 months • Joint attention • Social referencing • Social imitation and monitoring

12. Results of following high risk infants • 9 infants followed prospectively starting at 6 months of age. • Symptoms not present at 6 months of age • All infants at 6 months demonstrated: • Interest in social interactions • Showed social smile • Sustained eye contact and affective responses to mother • Responsive to others (Bryson, et.al 2006)

13. Results of following high risk infants • Symptoms developed for some infants by 12 months of age and for others by 18 months of age • 7 of the 9 children given diagnosis of ASD prior to 36 months of age

14. Findings of a Prospective Study of 50 infants • No group differences at 6 months of age • Between 12 and 18 months for the group later diagnosed with ASD displayed loss of skills • Loss of social communication behaviors • Gaze to face, smile, vocalizations • (Ozonoff, et al 2010)

15. Discrepancy • Changes in social communication development assessed through prospective research suggest a different picture of symptom onset from parents’ retrospective report.

16. Common Practice in Assessment • Gather information about symptom onset from parents, yet this practice may not be a valid assessment of slow decline in social communication that can be observed prospectively.

17. Recent Findings from Prospective Studies • Signs of ASD emerge over the first year or so of life in many children with ASD rather than being present from close to birth • Pattern of having ASD expressed prior to 6 months may be less common than once thought

18. Recent Findings from Prospective Studies • Traditionally defined categories of early onset and regressive autism do not paint the picture of how symptoms develop • Social communicative behaviors decrease rather than fail to progress

19. Recent Findings from Prospective Studies • Deficits and delays in emerging joint attention • Decreased response to name • Decreased imitation • Delays in verbal and non-verbal communication • Motor delay • Elevated frequency of repetitive behaviors, e.g. hand waving • Atypical visuo-motor exploration of objects • Extremes of temperament • Bryson, S.E.et al.(2007), Landa, R. and Garrett-Mayer, E. (2006), Yoder, P.et al.(2009)

20. Take Home Message about Prospective Studies • Currently identification of autism may not be possible in the majority of affected children by 12 months of age • American Academy of Pediatrics recommendations for screening at both 18 and 24 months is essential and may even need to be supplemented by screens after age 2 years. • C. P. Johnson, et al, May 2007,

21. Signs and Symptoms • National Research Council in its 2001 report Educating Children with Autism remarked “the manifestation of autism vary considerably across children and within an individual child over time. There is no single behavior that is always typical of autism and no behavior that would automatically exclude an individual child from a diagnosis of autism, even though there are strong and consistent commonalities, especially relative to social deficit.” • National Research Council, Committee on Interventions for Children with Autism. Educating Children with Autism. Washington, DC: National Academies Press; 2001

22. Differential Diagnosis • ASD • Intellectual Disability • Language Disorders • Obsessive Compulsive Disorder • Schizophrenia • Reactive Attachment Disorder

23. Making the Diagnosis • Practice parameters published by the American Academy of Neurology and the American Academy of Child and Adolescent Psychiatry indicated children who fail ASD screeners should have a comprehensive diagnostic assessment by experienced clinicians. • Filipek, et al. 2000, Volkmar et al. 1999

24. Comprehensive Evaluation Model • Interdisciplinary • Evaluates various areas of functioning • Gathers information across environments • Provides an integrated perspective • Communicates with schools and other providers • Provides recommendations

25. Components of a Comprehensive Evaluation • Developmental history • Physical exam • Establishing cognitive and language baselines • Assessment of social, communication, play, and behavioral presentation • Assessment of motor skills and sensory functioning

26. Components of a Comprehensive Evaluation • Laboratory investigation to search for know etiology or coexisting condition(s) • Medical concerns and co-morbidity • Adaptive functioning • Neuropsychological, educational, and vocational assessments • Assessment of possible family/parent support needs

27. Results of the Assessment Provides • Diagnostic clarification • Medical Findings • Profile of child’s strengths and challenges • Profile of child’s developmental level and adaptive functioning • Recommendations for evidenced-based developmental and educational interventions, as well as parent recommendations

28. Variables Neuropsychologists Consider • Information from multiple sources • Adaptive functioning • Social, communication, and behavioral problems • Family systems and needs

29. Variables Neuropsychologists Consider • Intellectual ability • Problem solving and learning style • Academic Functioning • Neuropsychological profile • Memory • Language • Executive functions • Motor • Visual Spatial

30. Typical Referral Questions • Diagnostic Clarification • Treatment Planning • Evaluation of Treatment Response • Eligibility for Services

31. The process of assessing autism • No medical test • Behavioral diagnosis • General Impressions • Questionnaires/Screenings • “Gold-Standard” measures

32. Assessment tools • Autism Diagnostic Observation Scale-Generic (ADOS-G) Lord et al. 2000 • Autism Diagnostic Interview (ADI-R) • Structured interview with parents Lord et al. 1994 • ADOS and the ADI-R are considered the “gold standard” for diagnosis • These instruments may lead to provisional diagnoses from as early as 18 months of age but tend to be more reliable with increasing age of the child • Western Psychological Services • http://portal.wpspublish.com/portal/page?_pageid=53,70384&_dad=portal&_schema=PORTAL

33. Autism Diagnostic Interview Revised (ADI-R) • Semi-structured based interview for caregivers • Interview may take between tow to three hours

34. ADOS • This semi-structured assessment assesses toddlers to adults, from children with no speech to adults who are verbally fluent who may have ASD. • Western Psychological Services • http://portal.wpspublish.com/portal/page?_pageid=53,70384&_dad=portal&_schema=PORTAL

35. ADOS • The ADOS consists of various activities; the clinician observes social and communication behaviors. • Look for target behaviors through specific use of toys, activities, and questions • Repetitive behaviors, sensory sensitivities, restricted interests observed and coded • The ADOS includes four modules, each requiring 35 to 40 minutes to administer. Modules based on communication level. • Western Psychological Services • http://portal.wpspublish.com/portal/page?_pageid=53,70384&_dad=portal&_schema=PORTAL

36. ADOS • ADOS activities for a child who is nonverbal to single word utterances • Free play • Response to name • Joint Attention • Bubble Play • Anticipation of a Routine With Objects • Responsive Social Smile • Anticipation of Social Routine • Functional and Symbolic Imitation • Birthday Party • Snack

37. Usually sensory interest in Play Material/Person

38. Free play • Seek engagement with examiner or caregiver • Exploration of materials symbolic/functional • Length of time engaged in activity

39. Bubble Play • Elicit eye contact and vocalization in coordination with pointing or reaching in order to direct the attention of parent or examiner

40. Anticipation of a routine with objects • Child’s affect • Initiation of joint attention • Shared enjoyment • Requesting • Motor behavior

41. Anticipation of a Social Routine • Assess the child’s anticipation of, request for, and participation in a social routine

42. Cognitive/Developmental Assessment • Children with an ASD also have signs of intellectual disability, averaging 44% in 2004 and 41% in 2006 • http://www.cdc.gov/ncbddd/features/counting-autism.html • Level of intellectual functioning is associated with severity of symptoms, ability to acquire skills, level of adaptive functioning, and outcome. • Filipek et al. 1999

43. Intellectual Assessment • Behaviors that interfere: • High distractibility • Off task behaviors • Social difficulties • Unusual use of language • Anxiety

44. Training to help increase responsiveness to testing environment • May need to teach the child how to sit in a chair for 5 minutes • May need to teach a child how to accept and trade toys • Addressing behavioral concerns • Enhance the child’s motivation • Conducted testing over multiple sessions • Frequent reinforcement breaks

45. Intellectual Assessment • Intelligence tests for children with spoken language • Wechsler Scales(WPPS-III, WISC-IV, WASI, WAIS III) • Differential Ability Scales, 2nd edition • Stanford-Binet 5th edition • Kaufman Assessment Battery for Children, 2nd edition

46. Intellectual Assessment • Nonverbal Children • Leiter International Performance Scale- Revised

47. Developmental Assessment • Children under the age of five • Bayley Scales of Infant Development-II • Ages 1 to 42 months • Mullens Scales of Early Learning • Ages 1 to 60 months

48. Predictive Value of Intellectual Assessments • Research has consistently documented that IQ at age 5 correlates with adult outcomes • It is unclear if IQ at 2 or 3 correlates with adult outcomes

49. Attention with ASD • Focusing • Tend to over focus on extraneous details (Fein et al., 1990) • Distracted by special interests • Sustaining • Children with ASD usually do not have a problem with sustained attention (Garretson, et al. 1990) • Shifting

50. Attention with ASD • Continuous performance tests • TEA-Ch (Manly et al. 2001) • Assess attention and activity level across environments with questionnaires • CBCL (Achenbach, 1991) • BASC (Reynolds and Kamphaus, 1998) • BRIEF (Gerard A. Gioia, 2002)