Michael J. Lucido, PhD Charlevoix Center Supervisor Christine Lennon, MA, LPC

1. Child Abuse Council Spring ConferenceStrengthening the Social and Emotional Health of Children:Autism Spectrum Disorder Overview Michael J. Lucido, PhD Charlevoix Center Supervisor Christine Lennon, MA, LPC DD Children’s BehavioRalServiceS April 26, 2013

2. Raise your hand if you personally know someone impacted by autism or Asperger’s.

3. Prevalence Rate

4. Taking a Look at Autism

5. Stephen Wiltshire’s Story Following 20 minute ride, he drew an 18 ft long drawing of New York city in exact detail

6. Pervasive Developmental Disorders

7. DSM-V Autism Spectrum Disorder (ASD)

8. Grandinwrote, • “As a child I remember Mother asking me time and again, ‘Temple, are you listening to me? Look at me.’ Sometimes I wanted to, but I couldn’t...”

9. Autism Spectrum Disorder Criterion ASD

10. Behavioral Signs and Symptoms • Speech: monotone, rhythmic, nasally/high pitched (dysarthric), pedantic, repeating phrases (echolalic), and other idiosyncratic speech patterns. • Eye contact: no, limited, or inappropriate eye contact- towards the ceiling, looking at the body, avoiding face/eyes. • Gross and fine motor coordination: unable to balance on foot or tandem walk, or poor writing (dysgraphia). • Stereotyped behaviors: hand-wringing or twisting, spinning in chair, complex whole body movement, hand-flapping, pacing.

11. Sensory Disturbances • Behavior “meltdowns” are often sensory related • Grandin wrote, • “But when I was in the world of people, I was extremely sensitive to noises..The pain that racked my head when the fog horn sounded was excruciating”. (hyperacusis-sensitivity) • “Spinning was another favorite activity. I’d sit on the floor and twirl around. The self-stimulatory behavior made me feel powerful, in control of things…I realize that non-autistic children enjoy twirling around in a swing, too. The difference is that autistic child is obsessed with the act of spinning”.

12. Understanding the “Behaviors” • Common misnomers about behaviors: • He can control his meltdowns! • She is being oppositional! • He just wants it his way! • He can stop biting himself! • It is an underlying neurological condition-first and foremost • Most of the time is out of their control • They struggle to be “normal”

13. What Causes Autism?

14. Is it the parents? • Kanner said autism is a result of “genuine lack of maternal warmth”. • Bruno Bettleheim said autism was caused by maternal coldness. • Finally by 1960s, Bernard Rimland said it was a neurological disorder.

15. Temple Grandin’s Story Graduated with a doctoral degree in animal science, wrote many books on autism and animal issues

16. A Few Theories on the Cause of ASD • No single theory explains ASD • Genetic and heredity • Abnormal development • Physical health issues • Autoimmune problems • Environmental toxins

17. Heredity & Genetic Abnormalities • Monozygotic twins as high as 60-95% and siblings are 45-60 times greater to develop autism • First degree relatives might have psychiatric issues like depression, OCD, anxiety disorders, etc • X Chromosome as a factor? • Fragile , Turner’s syndrome, Klinefelter, Rett, Prader-Willi, Timothy, Phenylketonuria, and Angelman syndromes. • Reason for higher rates in males? (XY vs. XX in females)

18. Developmental Growth • 20-30% have seizures, up to 72% abnormal EEG • 75% smaller head circumferences at birth, but rapid growth by first year in the 85th percentile • 100-200g heavier brain weight in autism • Deficits in Emotion centers: amygdala, prefrontal cortex, temporal lobes, & thalamus • Dysregulated neurochemicals like serotonin, dopamine, melatonin, and oxytocin

19. Neurological pathways for ASD

20. Gastrointestinal Problems • Gastrointestinal problems as high as 84% • Constipation, problems going to the bathroom, etc • These health issues impact moods, behaviors, appetite • Interaction between the gut and the brain is important to understanding ASD-serotonin? • Food allergies is strongest link to GI issues • Food allergies have been attributed to conditions like celiac disease, which lead to the abdominal problems

21. Autoimmune response • Lowered immune response • High opioid activity • High pain thresholds- high endorphin levels • Endocrine system related to thyroid • Concerns regarding hypothyroidism or low thyroid will impact brain development • Considered an iodine deficiency in prenatal and neonatal development

22. Environmental toxins • Industrialization increased exposure to neurotoxins • Heavy metals like mercury, lead, or cadmium • Pesticides such as cyanide. • Clothing, food, building materials, personal care • New Jersey has highest rates for autism & asthma-has highest pollution levels in the nation • Wakefield: vaccines link to autism retracted • 18 controlled epidemiological studies found no link • No one factor accounts for autism

23. Diagnosing autism Evidenced based practices

24. What is evidenced-based practice?

25. A Need for Comprehensive Care

26. History of Lack of Funding for Services • Costs are $35 billion per year nationwide • Average costs:$29,000-$43,000 per year • History of disparity of Federal funding • President proposed $1 billion increase of annual federal spending on autism • Michigan Department of Community Health expanded autism services

27. MDCH Autism Services Expansion • Created the 1915i State Plan Amendment and 1951b Mental Health Specialty Services and Support Waiver • Started April 1, 2013 • Consist of early identification-average age of child being diagnosed with autism is age 8 in Michigan. • Targeted18 months through age 5

28. ASD Screening and Diagnosis • Screening forms by parent and referred by pediatrician • Modified Checklist for Autism in Toddlers (16-30 mo.) • Social Communication Questionnaire (ages 2 ) • Referred to Access Center for a more in depth diagnostic evaluation. • Evaluation will consist of an in depth clinical interview, assessment, and other tests for behaviors, ability, language, etc as needed. • Diagnosis must be confirmed by a fully licensed psychologist or physician/psychiatrist.

29. Questionnaires Assessment • Autism Diagnostic Interview-“Gold standard” (ADI) • Autism Spectrum Rating Scales (ASRS) • Autism Treatment Evaluation Checklist (ATEC) • Modified Checklist for Autism in Toddlers (MCHAT) • Asperger Syndrome Diagnostic Scale (ASDS) • Gilliam Autism Rating Scale: 2nd Edition (GARS2) • Childhood Autism Rating Scale (CARS) • Social Communication Questionnaire (SCQ) • Social Responsiveness Scale (SRS)

30. Psychological Testing

31. Looking Beyond IQ • University of Montreal found intelligence tests (WISC, WAIS) in ASD over-diagnosing ID • None of the children scored in the high average range and a 1/3 scored in the ID range • Nonverbal IQ test, a 1/3 scored in the high average range, and only 5% scored as ID • Newer intelligence tests have profiles for ASD to explain such conflicting results

32. Kim Peek’s Story • Inspired by movie Rain Man • Read two pages at once • Memorized 12,000 books • Low average IQ

33. Neuropsychological Testing

34. Reading the Mind’s Eye Test • Visual-perceptual processing • Problems with facial recognition, and social-emotional processing. • Social cognitive test for empathy or “Theory of Mind”. • Bestway to evaluate social issues is through observations.

35. Occupational/Speech Assessment • Special education ASD evaluations include speech and occupational evaluations when identifying ASD. • CMH provides contractual support for OT and Speech when physician has ordered interventions for ASD in the home.

36. Need for Medical Evaluations • Gastroenterologist- problems with intestines and stomach including issues like constipation • Neurologist- brain imaging like CT scans and brain function with EEG • Immunologist/allergist- identify potential environmental allergies influencing behaviors • Dietitian- identify health habits • Psychiatrist- medications for behavior and mood

37. Autism Interventions Evidenced-based practices for ASD

38. Optimizing Life Pursuits in ASD Grandin wrote, “I think the same principle applies to autistic children-work with them instead of against them. Discover their hidden talents and develop them”.

39. Person-Centered • Assist parents and individuals with ASD: • Understanding procedures, aid in documents, ease transition in services, respect, be flexible. • PC seeks collaboration with natural supports and community. • Empathy, unconditional positive regard: • Individuals with autism are often on a one way street-walk with them for a while!

41. MDCH ASD Behavioral ServiceS • Provided to age 18 months-5 y/o • Applied Behavior Analysis (ABA) • Science of the principles of behavior • Two levels of service intensity for ABA • Early Intensive Behavioral Intervention (EIBI) • Children with a diagnosis of autistic disorder • Average of 10-20 hours per week • Applied Behavioral Intervention (ABI) • Children with a diagnosis of Aspergers, PDD, etc • Average of 5-15 hours per week

42. How services will be conducted • Structured applied behavior analysis program that relies upon discrete trial training (DTT) methods and incidental teaching opportunities • Administered in a child’s home or a clinic setting.

43. Discrete Trial Training • Comprehensive structured behavioral intervention or discrete trial training (Lovaas, 1987) • Operant conditioning (Skinner): rewarding specific behaviors to increase the likelihood of the behavior occurring again • Learning environment is structured • Target behaviors are broken down into discrete subskills • Initiated and selected by adult • Child’s response is prompted • Reinforcers are unrelated to the target response (e.g. toy) • Rewards for correct response or successive approximations

45. Developmental, Individual Difference, Relationship-Based (DIR) Floortime Model (Greenspan, 2000) Infants to preschoolers improve social-emotional cognition Motive, planning, and sequencing http://www.youtube.com/watch?v=jrXGh9bT0Sw DIR Floor-Time

46. Pivotal Response Training • Pivotal response training: teaching core or pivotal skills makes it easier for children with autism to learn basics (Koegelet al., 2001) • Increasing motivation to engage in social communication • Motivation • Self-regulate behaviors • Initiate social interactions • Response to multiple social cues

47. Cognitive-Behavioral Therapy • Social skills training • Anger management • Rethinking perspective • Regulate emotions • Social skills training • Social Autopsies • Social Stories

48. ASD Psychopharmacology I

49. ASD PsychopharmacologY II

50. Dietary and Vitamins • Ketogenic diets (used in seizure disorders) and gluten-casein free diets (used in schizophrenia) • Melatonin for initiating sleep • Fish Oil (EFA) improves cognition • Vitamin D to improve mood, sleep, cognition • Vitamin B6 and B12 to improve cognition • Oxytocin improve social affect and social cues • Recommendations come from physicians • Dietitians may provide nutrition consultation