AUTISM SPECTRUM DISORDERS

Sue Mondak, M.A., CCC-SLP

PREVALENCE OF ASD

Prior to 1990’s: 4-5 per 10,000 for autism

2003 California study: Doubling in last 4 years

CDC 2007: 1 in 150 CDC 2009: 1 in 110 CDC 2012: 1 in 88 CDC 2012: 1 in 54 boys

PREVALENCE (con’t)

More children will be diagnosed with autism this year than with AIDS, diabetes, or cancer combined.

Autism is the fastest growing developmental disorder in the United States.

DEFINITION - Educational

A brain development disorder characterized by impairments in social interaction, communication, and restricted and repetitive behavior, typically appearing during the first three years of life.

DEFINITION – CENTERS FOR DISEASE CONTROL (CDC)

Autism Spectrum Disorders are a group of developmental disabilities that can cause significant social, communication, and behavioral challenges.

Symptoms can range from mild to severe.

DEFINITION - DSM-IV

Qualitative impairments in social interaction

Qualitative impairments in communication

Restricted repetitive and stereotyped patterns of behavior, interests, and activities

DEFINITION (con’t)

Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3: Social Interaction Language as used in social

communication Symbolic or imaginative play

ASPERGER SYNDROMEDSM-IV

Qualitative impairments in social interaction

Restricted repetitive and stereotyped patterns of behavior, interests, and activities

Clinically significant impairments in social, occupational, or other important areas of functioning

ASPERGER SYNDROM (con’t)

No clinically significant general delay in language

No clinically significant delay in cognitive development or in the development of age appropriate self help skills, adaptive behavior (other than social interaction) and curiosity about the environment in childhood

PROPOSED REVISION FOR DSM - V

Rett’s disorder removed from autism category

All pervasive developmental disorders will be called Autism Spectrum Disorder

Minor changes to criteria

CAUSES OF AUTISM

No one knows exactly why, but the brain develops differently in people with autism.

It is now widely accepted by scientists that a predisposition to autism is inherited.

It is likely that both genetics and environment play a role.

GENETICS Researchers have identified a number

of genes associated with ASD. Identical twin studies show that when

one twin is affected there is up to 90% chance the other twin will be affected.

In families with one child with ASD, the risk of having a second child with the disorder is approximately 5%.

ENVIRONMENTAL FACTORS A number of pre or post-natal

environmental factors have been claimed to contribute to ASD or exacerbate it’s symptoms with little evidence to support these claims Certain foods (Glutton free diets) Infectious disease Heavy metals (Detox methods) Solvents Diesel exhaust

ENVIRONMENTAL FACTORS (con’t)

PCB’s Phthalates & phenols used in plastic

products Pesticides Alcohol Smoking Illicit drugs Vitamin deficiencies (Supplements) Vaccines

A recent Danish study found that pregnant women who had the flu were 2x more likely to have a child with autism

EARLY WARNING SIGNS: No big smiles or other warm, joyful

expressions by 6 months of age or after No back and forth sharing of sounds,

smiles, or other facial expressions by 9 months of age

No babbling by 12 months of age No back and forth gestures such as

pointing, showing, reaching, or waving by 12 months of age

WARNING SIGNS (con’t)

Lack of eye contact and response to name

No words by 16 months of age No meaningful two word phrases

(not including imitating or repeating) by 2 years of age

Any loss of speech, babbling, or social skills at any age

SOCIAL RECIPROCITY

Definition: The ability to initiate and respond in social interactions

SOCIAL RECIPROCITY IN CHILDREN WITH AUTISM

Less frequent spontaneous bids for communication

Fewer back and forth turns in interaction Fewer gestures Inability to recognize communication

breakdowns More reliance on structured situations for

conversation More passive conversational style

SOCIAL RECIPROCITY IN OLDER CHILDREN WITH AUTISM

Difficulty maintaining conversations with relevant remarks, questions, or comments

Difficulty providing necessary background information for conversations

Difficulty engaging in conversations appropriate to social context or interests of others

NONVERBAL COMMUNICATIONIN YOUNG CHILDREN WITH ASD

Limited range of conventional gestures and vocalizations

Reliance on contact gestures such as hand leading, pulling, or physical manipulation

Delayed or absent conventional gestures or distal gestures (pointing)

Use of problem behaviors to communicate (frequent tantrums)

NONVERBAL COMMUNICATION IN OLDER CHILDREN WITH ASD

Literal understanding and use of verbal communication

Limited understanding of sarcasm and nonliteral language

Monotone speech or atypical prosody

SYMBOLIC PLAY

Limited functional use of objects with younger children

Repetitive or rigid play Limited ability to represent objects

when younger and social situations when older

VERBAL COMMUNICATION IN CHILDREN WITH ASD

Reliance on immediate or delayed echolalia

Reliance on rote memory rather than semantic understanding for longer utterances

Persistent difficulty with comprehension

VERBAL COMMUNICATION (con’t)

Difficulty generalizing meaning of words beyond contexts in which they were learned

Difficulty learning words other than nouns at early stages

Difficulties with phonology or motor planning for speech

LITERACY SKILLS

Difficulty observing or imitating functional use of books

Limited understanding or use of story grammar

Poor reading comprehension Hyperlexia

SENSORY DIFFICULTIES Difficulty processing sensory input Senses may be hyper-sensitive or hypo-

sensitive; usually a combination Tastes Smells Touch Sounds Sights Movement and Balance Body Position/Muscle Control

SENSORY REGULATION Use of immature or atypical self-

regulation strategies Chewing on clothing Carrying objects Vocal play Rocking Visual Stimulation Covering ears / or dropping objects to hear

the sound Smelling toys or other objects frequently

ASSESSMENT

Primary assessment is through observation of communication, behavior and social interaction

Parental input and developmental history are essential components of the evaluation

ASSESSMENT (con’t)

Screening tool: M-CHAT (doctors often complete in

office) Used to identify children at risk, not

to determine diagnosis Child who fails 3 total items or 2

critical items (2,7,9,13,14,15) fail the M-CHAT

ASSESSMENT (con’t)

ADOS: Autism Diagnostic Observation Schedule A semi-structured, standardized

assessment of communication, social interaction, and play or imaginative use of materials

DIAGNOSIS

May obtain a medical diagnosis from child Psychiatrist, or behavioral pediatrician

Educationally: must meet eligibility qualifications

EDUCATIONAL ELIGIBILITY

See Michigan’s Definition of Autism Spectrum Disorder Handout

INTERVENTION STRATAGIES

Visual Schedules Picture Exchange System (PECS) Sensory Integration Therapy (OT’s)

INTENSIVE INTERVENTIONS

Behavioral / ABA (Applied Behavior Analysis)

Developmental Greenspan/Weider DIR/Floortime 6 Functional Developmental Levels

Combined Denver Early Start Model

DIR Framework (Greenspan/Weider)

Developmental, Individual differences and Relationship based

One-on-one intensive engagement Child centered-’meet them where

they’re at’ DIR is the theory, “Floortime” the

practice 15-25 hour/week beside school 6 Functional developmental levels

6 FUNCTIONAL DEVELOPMENTAL LEVELS

Self regulation and shared attention(FDL1)

Engagement (FDL 2) Two-way Communication (FDL 3) Complex two-way Communication (FDL 4) Shared Meanings & Symbolic Play (FDL 5) Emotional Thinking (FDL 6)

P.L.A.Y. Project ModelPlay and Language for Autistic Youngsters

Developed by Dr. Richard Solomon from the University of Michigan in 2000

Based on Greenspan’s Floortime/D.I.R. Model

Developed due to no intensive services publicly in Michigan

Community based, family centered, cost effective

Now in 27 states and 9 countries Attempting to bring this to our area

P.L.A.Y. Project Values Family and child centered Interventions often in the natural

environment of the home Parent empowerment model Relationship based Playful and fun Addresses the core deficit: Social

Impairment

DEVELOPMENTAL METHODS AND OUTCOMES OF THE PROJECT

Contingent, reciprocal, social interactions Follow the child’s lead, interests, and/or

intent Shared social attention Joyful relating Simple and complex nonverbal gestures Long interactive sequences of

spontaneous verbal communication Symbolic language related to affect

P.L.A.Y. Home Consultation

Monthly half day visits Coach, model, and support parents

to Play Video/written feedback

GOAL:

To move the child out of their Comfort Zone, into interactional engagements with others

To move the child from their current functional developmental level to the highest functional developmental level possible

COMFORT ZONE What the child does when you let them

do whatever they want to do Focused on repetitive interests Tuned out; “In their own world” Examples:

Lining up toys Visually self stimming on wheels, lines,

objects Obsessed with numbers and letters Stuck on same topic: planets, Pokemon

ACTIVITIES FOR FUNCTIONAL DEVELOPMENTAL LEVELS 1 & 2

Rolling child up in a rug Swinging in a blanket Tickling Gentle wrestling Playing peek-a-boo Sensory Motor level

ACTIVITIES FOR FUNCTIONAL DEVELOPMENTAL LEVELS 3 & 4

Chase: “I’m gonna get you” Get the bubbles, balloon, etc. Ball play (rolling it back and forth) Very simple pretend play: phone to

ear, cars crash Being silly

ACTIVITIES FOR FUNCTIONAL DEVELOPMENTAL LEVELS 5 & 6

Pretend play: Dress up, tea party Real Hide-n-Seek (not just peek-a-

boo) Reading books – looking at

pictures and a telling a simple story

Duck, duck, goose

RESEARCH The P.L.A.Y. Project is a form of Intensive

Developmental Intervention (IDI) Studies have found that Intensive

Interventions that incorporate parent training, and focus on the core deficit of ASD (social impairment) show significant improvement in children with autism

Demonstrated improvements in parents skill in interaction and child functional development

EEG brain scans confirm improvements