Autism Spectrum Disorder and Toddlers

1. Autism Spectrum Disorder and Toddlers Regional Autism Spectrum Team Cork & Kerry September 2013

2. Aims of this session To increase your knowledge of: • Current best practise guidelines re Assessment of toddlers with possible ASD • Typical toddler development in the areas of social interaction, play and communication • Signs of an ASD in a toddler.

3. Autism Diagnostic Assessments and Toddlers • Parents generally identify concerns regarding their’s child’s development between 12-18 months. (Zwaigenbaum et al,2009) • Clinical guidelines on the early identification, screening, and diagnosis of ASD recommend that 18- and 24-month-olds be screened for an ASD. (NICE guidelines,

4. 1. Best Practise Guidelines on screening and assessment with Toddlers. • The following information is mainly based on: • NICE Clinical guidelines: Autism diagnosis in children and young people. Recognition, referral and diagnosis of children and young people on the autism spectrum. (2011) • Scottish Intercollegiate Guidelines Network (SIGN). (2007) Assessment, diagnosis and clinical interventions for children and young people with autism spectrum disorders. A national clinical guideline. • Also consulted the Canadian best practise, Californian Best practise and the Vermont Best practise guidelines.

5. Be aware that in some children and young people there may be uncertainty • about the diagnosis of autism, particularly in: • children younger than 24 months • children or young people with a developmental age of less than 18 months • children or young people for whom there is a lack of available information about • their early life (for example some looked-after or adopted children) • older teenagers • children or young people with a complex coexisting mental health disorder (for • example ADHD, conduct disorder, a possible attachment disorder), sensory • impairment (for example severe hearing or visual impairment), or a motor disorder • such as cerebral palsy.

6. The assessment of children and young people with developmental delay, emotional and • behavioural problems, or genetic syndromes should include surveillance for ASD as part • of routine practice. •  Healthcare professionals should consider informing families that there is a substantial • increased risk of ASD in siblings of affected children. • C The use of an appropriate structured instrument may be a useful supplement to the • clinical process to identify children and young people at high risk of ASD

7. The evidence regarding the minimum age at which ASD can be reliably diagnosed is not clear. • Findings suggest that: • the diagnosis of autism is always more reliable and stable than the diagnosis of other autism • spectrum disorders, regardless of age, and can be reliably diagnosed between the ages of • 2-3 years by experienced healthcare professionals.39, 40 • in children later identified as having ASD, features reported when they were under two • years may have been non-specific.41

8. Early identification is essential for early therapeutic intervention and leads • to a higher quality of life for the child and family

9. Social-communication, notably a lack of/atypicalities in • Eye gaze and shared/joint attention • Affect and its regulation (eg, less positive and more negative affect) • Social/reciprocal smiling • Social interest and shared enjoyment (in absence of physical contact such • as tickling) • Orienting to name called • Development of gestures (eg, pointing) • Coordination of different modes of communication (eg, eye gaze, facial • expression, gesture, vocalization) • Play, notably • Reduced imitation of actions with objects • Excessive manipulation/visual exploration of toys and other objects • Repetitive actions with toys and other objects • Language and cognition, notably a lack of/delays or atypicalities in • Cognitive development • Babbling, particularly back-and-forth social babbling • Language comprehension and production (eg, odd first words or • unusually repetitive) • Unusual prosody/tone of voice • Regression/loss of early words and/or social-emotional • engagement/connectedness • Visual/other sensory and motor, notably • Atypical visual tracking, visual fixation (eg, on lights) and unusual • inspection of objects • Underreactive and/or overreactive to sounds or other forms of sensory • stimulation • Decreased activity levels and delayed fine and gross motor skills • Repetitive motor behaviors and atypical posturing/motor mannerisms • Atypicalities in regulatory functions related to sleep, eating, and attention

10. First, some children with ASDs, particularly those • with more intact language and intellectual development, • may have more subtle symptoms at an early age.44,50 • Speech delays are often the concern that parents first • report, so for children without marked delays, early • symptoms may be less apparent. As well, a proportion of • children with ASD symptoms may show “plateauing,” • deceleration, or frank losses in cognitive and social development • or functioning in the second year.44,48,50 Thus, • mild symptoms and even an absence of symptoms at 18 • months do not “rule out” a later diagnosis of ASDs. • Ongoing surveillance and follow-up are essential, particularly • for children who are referred because of early • concerns but do not initially receive an ASD diagnosis

11. Second, it may be difficult to distinguish between • ASDs and other atypical patterns of development at an • early age. This may be especially true among infant • siblings of children with ASDs, who are at risk not only • for ASDs but also for a broader spectrum of delays including • but not limited to the areas of emotion expression • and referential communication.20,53,94–98 Similarly, • early diagnosis of ASDs may be difficult in toddlers with • severe developmental delays, or impairments in vision • and/or hearing, for whom standardized diagnostic instruments • have shown limited specificity.80,99

12. Often, a misdiagnosis that • results in a child failing to receive necessary services is the greatest concern. On the other • hand, over-diagnosis has negative consequences for individual children, public health • strategies and research.

13. Toddlers diagnosed with an ASD according to the DSM-5 were found to represent a more impaired population compared to those who qualified for a diagnosis of an ASD based on the DSM-IV-TR, but not the DSM-5. The group diagnosed according to the DSM-IV-TR represented a population of toddlers who were more impaired than atypically developing peers. • Conclusions: The proposed changes to the DSM will likely result in those diagnosed with an ASD according to the new criteria representing a more functionally impaired group

14. Population screening for ASD is not recommended. False positive or false negative results from • inappropriate use of screening tests may delay correct diagnosis. The decision about the need • for referral and further assessment should be made on clinical grounds. As part of the core programme of child health surveillance, healthcare professionals • can contribute to the early identification of children requiring further assessment for • ASD, and other developmental disorders: • clinical assessment should incorporate a high level of vigilance for features • suggestive of ASD, in the domains of social interaction and play, speech and language • development and behaviour • CHAT or M-CHAT can be used in young children to identify clinical features • indicative of an increased risk of ASD but should not be used to rule out ASD.

16. delay or absence of spoken language • looks through people; not aware of others • not responsive to other people’s facial expression/feelings • lack of pretend play; little or no imagination • does not show typical interest in or play near peers purposefully • lack of turn-taking • unable to share pleasure • qualitative impairment in non-verbal communication • does not point at an object to direct another person to look at it • lack of gaze monitoring • lack of initiation of activity or social play • unusual or repetitive hand and finger mannerisms • unusual reactions, or lack of reaction, to sensory stimuli

17. abnormalities in language development including muteness odd or inappropriate prosody persistent echolalia reference to self as ‘you’, ‘she’ or ‘he’ beyond three years unusual vocabulary for child’s age/social group limited use of language for communication and/or tendency to talk freely only about specific topics       Social impairments inability to join in play of other children or inappropriate attempts at joint play (may manifest as aggressive or disruptive behaviour) lack of awareness of classroom ‘norms’ (criticising teachers, overt unwillingness to cooperate in classroom activities, inability to appreciate or follow current trends) easily overwhelmed by social and other stimulation failure to relate normally to adults (too intense/no relationship) showing extreme reactions to invasion of personal space and resistance to being hurried      Impairments of interests, activities and/or behaviours lack of flexible cooperative imaginative play/creativity difficulty in organising self in relation to unstructured space (eg hugging the perimeter of playgrounds, halls) inability to cope with change or unstructured situations, even ones that other children enjoy (school trips, teachers being away etc)    Other factors unusual profile of skills/deficits any other evidence of odd behaviours including unusual responses to sensory stimuli

19. Early Communicate intent

20. First words

21. First words cont

22. Linguistic Structures

23. Echolalia One of the most Salient features of an ASD but NOT unique to ASD. Most common in ASD though. Immediate or delayed and functional or non-functional. Echolalia- also occurs in: • blind children, • children with language impairments, • older people with dementia • TYPICALLY DEVELOPING CHILDREN! For all children will decline over the course of development.