Elizabeth Crais The University of North Carolina at Chapel Hill TelAbility/WATCH Project

1. USING THE BEST AVAILABLE EVIDENCE TO IDENTIFY INFANTS AND TODDLERS WITH (OR AT RISK FOR) COMMUNICATION DEFICITS Elizabeth Crais The University of North Carolina at Chapel Hill TelAbility/WATCH Project January 11, 2008

2. Where We Are Now? • Clear evidence that early intervention works • Growing evidence across a variety of disabilities supports maxim “earlier ID is better” • 10-12% of school-age population receiving special education services • 12-16% of children have developmental or behavioral disabilities (Comm. on Child with Dis, 2001) • 7-24% of 2-3 year olds have social-emotional or behavioral deficits (Briggs-Gowan et al, 2001) • How early are we identifying these children?

3. Percentage of Children Identified For EI By Age Range • 1.6 % Birth to 2 years • 4.9% 3-5 years • 11% 6-18 years (U.S. Department of Education, 2005) • Even among those identified early 0 - 3: 14% 0-1 years 32% 1-2 years 54% 2-3 years (Part C Update, 2004) • Most commonly identified early concerns are related to motor or language delays

4. AreWe Using the Best Predictors? • One of best predictors of child’s future language is child’s current communication performance (Brady, Marquis, Fleming, & McLean, 2004; Facon, Facon-Bollengier, & Gruber, 2002). • Language skills are a strong predictor of cognitive skills (Brady et al, 2004).

5. Current Evidence Based Predictors • Vocal Behaviors • Vocabulary Comprehension • Prelinguistic communication • Gesture Use • Symbolic Play

6. Vocal Behaviors Predictive of Later Language • More vocalizations • More consonant-vowel syllables • Rate of vocalization • Rate of vocalizations with consonants • Rate of vocalizations in interaction with others (***). (McCathern, Yoder, & Warren, 1999). • Ability to use sounds is strongest predictor of language skills one year later (First Words)

7. Prelinguistic Communication • Rate of prelinguistic communication • Rate of symbol use (especially gestures) • Rate of different symbol use • Significantly correlated with later language outcomes 12 months later • Amount of prelinguistic communication predictive of later symbolic communication (Calandrella & Wilcox, 2000). • Frequency of nonverbal communication in preschoolers with ASD predicts language 1 year later (Sigman & Ruskin, 1999)

8. Motivation for Our Research in Autism • Diagnosis of children with autism typically occurs between 2 - 3 years of age • Diagnosis is rare before two years of age • Yet the literature shows enhanced outcomes with early identification and intervention • Thus, our ultimate goal is to identify children with autism even earlier • But what are the barriers to earlier identification?

9. Barriers To Early ID Include • Difficulty identifying behaviors that could be markers for group differences • Need to look for both presence of atypical behaviors and absence of typical behaviors • Limited knowledge of developmental course of behaviors that may be common in young children (e.g., repetitive movements, mouthing) • Therefore, relatively “late” identification makes it difficult to know the course of early development in these children

10. Retrospective Video Analysis • Ecologically valid methodological tool for earlier identification of children at very early periods in development (prior to diagnosis) • Several retrospective video studies of autism suggested young children with autism can be distinguished from typically developing children (Adrien et al., 1993; Baranek, 1999; Osterling and Dawson, 1994)

11. Retrospective Video Analysis • UNC researchers have used footage that families provided of their child under two years of age (well before diagnosis). • Footage representative of a wide range of family play situations. • Videotapes edited for randomly selected cross-section of situations and events. • Studies include typically developing infants, infants later diagnosed with autism, and infants diagnosed with developmental delays at 9-12 and 15-18 months of age. (Baranek, 1999; Watson, Crais, Baranek, Roy, & Dykstra, 2004; Lanter, Colgan, McComish, Watson, Baranek, & Crais, submitted).

12. Possible Behaviors of Interest • Increasing interest and research in early prelinguistic behaviors in children developing typically and with autism • Areas of promise targeted today are gesture use, play development, and relationship between play behaviors and gesture use • Helpful to first be familiar with typical development in these areas

13. Development of Gestures: Why Are They Important? • Early means to communicate • One of the first signs of intentionality • Can be used in profiling skills • Can be helpful in identifying delays • Important to intervention planning

14. Gesture Development and Use • Amount of gesture use can help distinguish between “late talkers” and children with true language deficits (Thal & Tobias, 1992; 1994). • Early onset of pointing predictive of advanced language skills (Butterworth & Morisette, 1996). • Use of distal (e.g., show, give, point) gestures predictive of higher rate of communication (McLean, McLean, Brady, & Etter, 1991).

15. What Are Gestures? • Gestures are actions produced with the intent to communicate and are typically expressed using the fingers, hands, and arms, but can also include facial features (e.g., lip smacking for "eating") and body motions (e.g., bouncing for “horsie") • (Iverson & Thal, 1998)

16. Age Ranges of Emergence of Common Gestures • Reaching 6-9 months • Giving 8-11 months • Showing 8-13 months • Pointing 9-14 months (Bates et al., 1975; Carpenter, Nagell, Tomasello, 1998; Crais, Douglas, & Campbell, 2004; Masur, 1983)

17. Functions of Gestures • Social interaction: initiating or sustaining a social game or routine, providing comfort, teasing, showing off • Behavior regulation: regulate behavior of others to obtain an object, get them to carry out action, or stop someone from doing something • Joint attention: direct other’s attention in order to comment on an object or event, provide information on an object or event, or acknowledge shared attention to an object or event

18. Age of Emergence of Functional Categories • Protests 6-8 months • Requests for actions 6-10 months • Requests for objects 6-10 months • Comments 8-11 months • Answering 13-16 months • (Carpenter, Mastergeorge, & Coggins, 1983; Crais et al, 2004)

19. Array of Gestures Seen in 9-12 Month Old Children (Crais et al, 2004) • Behavior Regulation • Protest (use body, push away object with hand/s) • Request Objects (reach for object, pull on adult’s hand with object, point to obtain object) • Request Actions (reach to be picked up, do the action) • Social Interaction: • Seek Attention (body movement, grab hand, bang object) • Social Games (participate by imitating, initiate games) • Representational Gestures (“bye bye”, imitation clapping, show functions of objects) • Joint Attention: • Comment (show object, give object)

20. Array of Additional Gestures Seen in 15-18 Month Old Children • Behavior Regulation: • Protests (shake head “no”) • Request Objects (reach while opening & closing hand) • Request Actions (point, take hand of adult, give object) • Joint Attention: • Comment (point to object, point to object by request) • Social Interaction: • Seek Attention (show off) • Representational Gestures (hug objects, smack lips, clap for excitement/accomplishment), • (Crais et al, 2004)

21. Results: Comparing Group Means for Gesture Functions at Time 1 (9-12 m) totgest_1 ASD<TYP DD < TYP ASD < TYP (ASD n=24, DD n=14, TYP n=22)

22. Gesture Use In Infants & Toddlers • Results indicate differences in gesture use between 9-12 month old infants later diagnosed with autism or developmental disabilities and children with typical development. • Total number of gestures (differences between children with ASD & TYP, DD & TYP) • Group differences on behavior regulation & joint attention gestures, but not social interaction (9-12 & 15-18 months)

23. Gestures Seen in Sample

24. Levels of Play Development • Level 0 = No object play • Exploratory = the way infant examines the environment in order to gain information from objects or toys (e.g., mouthing, banging, shaking, poking): Level I (indiscriminate actions), Level 2 (simple manipulations of single objects) • Relational = two or more objects used in combination with one another, without regard to attributes or functions of objects (e.g., objects pushed, stacked, nested, piled): Level 3 (taking objects apart), Level 4 (general combinations)

25. Levels of Play Development • Functional = influenced by social or cultural properties of objects (e.g., pretend actions, spoon to doll’s mouth): Level 5 (directed toward object), Level 6 (toward self), Level 7 (toward doll), Level 8 (toward other person) • Symbolic = items, attributes not actually present, or substitution of objects: Level 9 (object substitution), Level 10 (agent play), Level 11 (imaginary play) • (Baranek, Barnett, Adams, Wolcott, Watson, & Crais, 2005; Belsky & Most, 1981; Casby, 1991, Knox, 1997; Libby, Powell, Messer, & Jordan, 1998; Lifter, Sulzer-Azaroff, Anderson, & Cowdery, 1993)

26. Age Ranges of Play Levels Exploratory • Level 1 (indiscriminate actions) 2 - 10 months • Level 2 (simple manipulations) 2 - 10 months Relational • Level 3 (Takes objects apart) 10 - 18 months • Level 4 (General combinations) 10 - 18 months Functional • Level 5 (object directed) 12 –18 months

27. Age Ranges of Play Levels Functional • Level 6 (self directed) 12 – 18 months • Level 7 (doll directed) 12 - 18 months • Level 8 (other directed) 12 - 18 months Symbolic • Level 9 (object substitution) 18 – 30 months • Level 10 (agent play) 18 – 30 months • Level 11 (imaginary play) 18 – 30 months

28. Concurrent Language/Play Associations 13 - 20 months • First words appear along with more consistent communicative gestures and single play schemes (e.g., child feeds self with spoon) 20 - 24 months • Word combinations appear along with single play schemes combined (e.g., child feeds self with spoon, then drinks from cup). • (Kennedy, Sheridan, Radlinski, & Beeghly, 1991)

29. Predictive Language/Play Associations • Early skill with communicative gestures predicts later language levels (Mundy & Gomes, 1998; Thal, Bates, Goodman, & Jahn-Samilo, 1997) • Early functional object play has been associated with later language ability (Lyytinen et al., 1999; Ungerer & Sigman, 1984) • Level of symbolic play exhibited is predictive of later language skills (Lyytinen, Laakso, Poikkeus, Rita, 1999; Lyytinen, Poikkeus, Laakso, Eklund, & Lyytinen, 2001).

30. Longitudinal Relations between Play and Gesture Behaviors in Infants with Autism(Watson, Crais, Baranek, Roy, & Dykstra, 2004) Examined predictive relations within and across the domains of play and gesture from 9-12 to 15-18 months

31. Subjects(Watson, Crais, Baranek, Roy, & Dykstra, 2004) • 27 children in three groups • Autism spectrum disorder (n = 15); DSM-IV criteria, verified by CARS scores, and for 10 of 15 by ADI-R • DD (n =4); nonspecific, mixed diagnoses • Typical (n = 8)

32. T1 to T2 Gesture Use (Watson et al. 2004) Figure 1: Mean Frequency of Gestures for Total Sample (p=.08)

33. T1 to T2 Gesture Use(Watson et al., 2004) Figure 2: Mean Frequency of Gestures for ASD Sample

34. T1 to T2 Higher Level Play (Relational Play+)(Watson et al., 2004) Figure 3: Mean Second in Higher Level Play for Total Sample

35. T1 to T2 Higher Level Play(Relational Play+)(Watson et al., 2004) Figure 4: Mean Seconds in Higher Level Play for ASD Sample

36. Clinical Implications • Preliminary guidelines for clinicians seeking developmental models for both the range of expected ages of emergence of targeted gestures and play behaviors and their hierarchy in typically developing children. • Clinicians can assess the depth and breadth of gestures and play behaviors used by children demonstrating communication delays • Hierarchy of gesture and play development can be used in determining potential developmental targets for intervention.

37. Red Flags Approach: Social Development • Be concerned if the child is not: By: • Responding to familiar adults with a social smile 3 months • “Talking” back by vocalizing to familiar adults who talk to child 8 months • Attentive to social games played by familiar adults (e.g., Peek-a-Boo) 8 months • Participating in social games (e.g., hands up for “Pat-a-Cake”) 12 months • Showing and/or giving objects to familiar adults 15 months • Pointing to objects to indicate interest in them 18 months • Seeking adult interaction to play with toys/look at books 18 months • Pointing either spontaneously or by request to pictures in books 24 months • *** General Social Concerns = inattentiveness to people, lack of eye contact or shared mutual gaze with familiar adults by 12 months; preferring to play alone at 18 months or older; social play is limited to “chase” or “tickle” games at 24 months.

38. Intentionality Be concerned if the child is not: By: Showing any type of intentional behavior (e.g. requests, protests) 10 months Communicating for a variety of reasons (e.g., protesting, requesting, seeking social interaction, commenting) 18 months Using a variety of means (e.g., gestures, vocalizations, eye gaze) 18 months *** General Intentionality Concerns = children who primarily regulate others behavior (e.g., putting someone’s hand on toy to operate it, leading adult to door to open it), but do not display more social forms of communicating (e.g., giving book to another to read, pointing to objects of interest, drawing attention to self for social reasons).

39. Play Skills Be concerned if the child is not: By: Mouthing, banging, shaking, and/or manipulating objects 8 months Throwing, dropping toys especially for others to get 12 months Participating in social games (e.g., looks for Mom during “Peek-a-Boo”). 12 months Giving or showing toys to adults 15 months Pushing, pulling, turning on, putting in, and taking out objects 18 months Showing knowledge of how to use toys functionally (e.g., push toy car) 18 months Stacking cups or rings on a toy stand (not necessarily correct) 24 months Performing some pretend play behaviors (e.g., drinking from empty cup) 24 months Combining play acts (e.g., rocks baby and puts down for nap) 30 months Playing with familiar children some of the time when in close proximity 36 months Taking turns in constructive or pretend play with familiar children 48 months *** General Play Concerns = children who primarily perform play behaviors representative of younger children; have limited play behaviors (e.g., play with only one type of toy, play very briefly with toys); seem averse to playing with others (including caregivers); play alone for longer periods of time than would be expected at their developmental age; have stereotypic play behaviors (e.g., repeatedly open and close drawers, line up their toys and become upset if others change the order); or display unusual play behaviors (e.g., rub plastic stacking rings over their hands or face, lick and smell toys).

40. Comprehension Skills Be concerned if the child is not: By: Looking at objects looked at by others 12 months Acting on objects that are noticed 12 months Imitating ongoing actions 12 months Responding to own name 15 months Attending to an object mentioned 15 months Doing what is usually done in a situation (e.g., child puts on coat when others do) 18 months Using conventional behaviors (e.g., combing hair with comb) 18 months Acting on objects as the agent (e.g., child brushes own teeth when asked to “Brush the baby’s teeth”) 24 months Responding to many object names 24 months Retrieving a familiar object out of sight 24 months

41. Sound Production Be concerned if the child is not: By: Producing cooing and gooing sounds 6 months Babbling in repeated sequences of sounds (e.g., baba, gaga) 11 months Producing 3 different consonant sounds (e.g., b, p, m, n, d, k, t, g, w) 18 months Imitating any non-speech sounds (e.g., truck sound, animal sounds) 18 months Using sound sequences that sound like talking 24 months Producing (VC) syllables (e.g., up), (CVC) syllables with a single consonant (e.g., cake), and some vocalizations or words with two or more different consonants (e.g., pat, tummy) 24 months Producing 6 different consonants 24 months Producing initial consonants in most words (says “at” for pat, “ot” for boat) 36 months Producing 10 different consonants 36 months Producing any final sounds (“bo” for “boat”, “e” for “eat”) 36 months

42. Word Productions and Word Combinations Be concerned if the child is not: By: Producing any words or word approximations 18 months Producing 50+ words or word approximations 28 months Producing 100+ words 30 months Combining words 28 months E. Crais. (2001). Identifying communication and related developmental disabilities in young children. In J. Roush (Ed.), Screening for hearing loss and otitis media in children. San Diego, CA: Singular

43. Questions?