rebecca landa, ph.d., director, center for autism and related disorders virginia creating...
TRANSCRIPT
Rebecca Landa, Ph.D., Director, Center for Autism and Related Disorders
Virginia Creating Connections to Shining StarsJuly 22, 2013
Early Intervention for Young Children with ASD:An Evidence-based Approach to Identification and Improving Outcomes
Disclosures
• None
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Thank you
• NIH• Autism Speaks• Families and children who participate• My wonderful staff
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Focus of this talk:
• Detection of autism spectrum disorders as early as possible– Early signs and trajectories
• Screening• Early intervention: Early Achievements
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Early Detection of ASD
• Why?
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Early Intervention is important because
• Early experiences influence brain development
• The brain is a thinking organ• It learns and grows by interacting with people
and objects, through perception and action• Able to continually adapt and rewire itself• Constraints – need good intervention
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Early experiences matter
Bids for attention
Attention from other
ConnectionSustained engageme
nt
Learning
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Richer, more diverse repertoire
Hopefully responsive: optimality of development
Developmental Cascades
Bids for attention
Attention from other
ConnectionSustained engageme
nt
Learning
8RewardingTomasello et al., 2005
Greater expansions in form and content
More highly specified and effectively directed
Developmental Cascades
Bids for attention
Attention from other
ConnectionSustained engageme
nt
Learning
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Less frequent
Less frequent
Briefer
Attenuated
Ambiguous, poorly integrated
Importance of early detection of ASD
• Early intervention experiences are designed to address core ASD deficits (Kasari et al., 2008; Landa et al., 2011)
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We want this:
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Landa, Holman, O’Niell, Stuart. (2011).Journal of Child Psychology and Psychiatry
Early Achievements Intervention: 1-year-olds
Note:*Purposeful*Notice each other*Imitating*Sustained meaningful engagement*Sequences of meaningful, intentional action
To understand the earliest behavioral markers of ASD
• Must begin in infancy, before we know the child will have ASD
• Research designs for doing so:
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Research Designs
• Retrospective studies – Interview parents about the past (problems with
memory of details)– Scoring home videos of older children diagnosed with
ASD• Videos made when children were infants or
toddlers
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Problem with Retrospective Designs
• Can’t control the context (cues, distractions, difficulty of task, camera angle)
• Can’t give the child specialized tests targeting specific behaviors or abilities of interest
• Can’t control the age
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Research designs
• Prospective studies– Highly efficient to study infants at increased genetic risk
for ASD– Can control the
• Age at time of assessment• Context (cues, camera angle, difficulty, distractions)• Types of tasks to study specific abilities
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To understand ASD in infants and toddlers
• Two groups studied:– High Risk (HR) for ASD: Infant siblings of children
with ASD– Low Risk (LR) for ASD: No family history of ASD
• Recently added a group at increased risk for delay, but less risk for ASD than HR infants: Preterm
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High risk for ASD
• High risk infants (younger sibs of children with ASD):
• 18.7% will have ASD (Landa et al., 2006; Landa et al., 2007; Ozonoff et al., 2011)
• 30% will have non-ASD language and social delays by the third birthday (Messinger et al., in press)
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Assessment ages
6 m 10 m
14 m
18 m
24 m
30 m
36 m
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Rate confidence of presence of ASD at each age
High Risk (HR)Low Risk (HR)
Outcome classifications
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36 month
s
ASD
Intermediate(Broader Autism Phenotype)
Unaffected
Autism Diagnostic Observation Schedule + Clinical judgment
Main points to be addressed
1. When do the signs of ASD first appear?2. What are those signs?3. What is the course of development for infants
and toddlers with ASD in the first 3 years of life?
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What are the first signs of ASD?When do the signs of ASD appear?
• At 6 months:– Signs are subtle– Most evident signs involve motor delay– Temperament: Passive– Social: Lower duration of self-generated looks to
parent
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Yellow Flags
When do the signs of ASD appear?
• At 6 months:– Signs are subtle– Most evident signs involve motor delay– Temperament: Reactivity, Distractability– Social: Lower duration of self-generated looks to
parent
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Typical head control: age 6 months
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*Baby is laid on flat surface*Make sure nothing of interest behind or above baby*Try to get baby’s attention*Gently pull on arms*Goal: Baby pulls self upward into sit with a little help
Evidence of poor postural control at age 6 months
• N=58 sibs-A at mean age 6 months• Clinical judgment of head lag scored from
videotapes of pull-to-sit item on Mullen GM Scale
ASD BAP Non Delay0
20406080
100
% with head lag
% with head lag
30%
59%
93%
How is the motor system developing in children with and without ASD?
• Participants– ASD n=52– Non ASD n=152
• Tested at 6, 14, 24, 36 months• Mullen Scales of Early Learning (Mullen, 1995)
– Fine Motor T score– Gross Motor T score
• Delay: scoring at least 1.5 standard deviations below the test mean on either motor scale
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% ASD and non ASD with motor delay from 6-36 months
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Motor Delay: Fine Motor and/or Gross Motor T score <35
6 mo 14 mo 24 mo 36 mo0
10
20
30
40
50
60
70
ASDNon ASD
% w
ith m
otor
de
lay
Examples of Mullen Early Motor Items
Gross Motor Fine Motor
Supports self on forearms when on tummy
Grasp reflex
Sits with support, head control Grasps peg touched to palm of hand (ulnar grasp)
Rolls over Reaches for and grasps block (radial palmar grasp, no thumb)
** Holds on to fingers, pulls self to sit
Transfers, bangs, drops
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Examples Later Mullen Motor Items
Gross Motor Fine Motor
Balances on one foot Imitates 4-block train
Runs, turns corner, stops Unscrews and screws nut and bolt
Hops at least two times Strings beads
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Clinical implication
• Motor score on a standardized test is not sufficiently sensitive at age 6 months to detect developmental disruption in infants at risk for ASD
• Quality of movement:– Postural control (head lag, changing positions)
• Likely to affect quality of imitation, gesture
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Trajectories in Sibs-A with and without ASD
• Sibs-A n=204• Low Risk Controls n=31• Tested:
– 6, 14, 18, 24, 30, 36 months• Measures:
– Mullen Scales of Early Learning – Communication and Symbolic Behavior Scales Developmental
Profile
Landa, Gross, Stuart, & Faherty. (2013). Child Development.
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Different onset patterns: 52 with ASD
Early Diagnosed: At 14 months
Later Diagnosed: After 14 months
• 28 (51.8%) • 78.5% male• 42.8% parents
concerned at age 6 mos
• 70.4% concerned at age 14 months
• 26 (48.2%) • 84.6% male• 29.4% parents
concerned at 6 mos • 65.4% parents
concerned at 14 mos
• At 14 mos: language or social delay
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IQ at Age 14 months
IQ0
20
40
60
80
100
120
Early DxLater DxNon-ASD
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Mullen Early Learning Composite
Receptive Language Raw Scores10
2030
40Sc
ore
6 14 18 24 30 36
Age (Months)
Non-ASD group Early Dx ASD group
Later Dx ASD group
rlraw
Landa, Gross, Stuart, Faherty. 2013. Child Development
• All groups WNL at 6 months
• Absence of typical language growth spurt in ASD
• Plateau in Early dx group
Frequency of Initiation of Joint Attention
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Another aspect of joint attention:
• Social attention:• Tuning in to others body language:
– gesture – gaze cues
• Understand that these cues ‘tell’ what the person is thinking about, what interests them
• By looking at the object of their attention, you ‘share attention’ with them
• This results in a moment of joint (shared) attention
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Shared positive affect
• When you look at someone and smile, you– Invite them to share something with you– Invite them to communicate with you– Make them feel that you want to connect with them
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Frequency of Shared Positive Affect
Landa, Gross, Stuart, Faherty. 2013. Child Development
Heterogeneity in Trajectories of Sibs-A
Latent class analysis: Heterogeneity
20
30
40
50
60
70
Mul
len T
-scor
e
6 14 18 24 30 36
Age (Months)
Accelerated class
20
30
40
50
60
70
Mul
len T
-scor
e
6 14 18 24 30 36
Age (Months)
Normative class
20
30
40
50
60
70
Mul
len T
-scor
e
6 14 18 24 30 36
Age (Months)
Early Language & Outcome Fine Motor Delay
20
30
40
50
60
70M
ullen
T-sc
ore
6 14 18 24 30 36
Age (Months)
Developmental Slowing
MSEL Fine Motor
MSEL Gross Motor
MSEL Visual Reception
MSEL Receptive Language
MSEL Expressive Language
Landa, Gross, Stuart, Bauman, 2012, JCPP
MSEL T scores
n=46 (22.3%) n=24 (12%)
Within-phenotype proportions in diagnostic classes
• •
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Group N Accelerated Normative Delay then catch up
Slowing
Early ASD 27 0 14.8 29.6 55.6
Later ASD 25 4 36 32 28
Clinical implications
• Mid infancy (6 months): – Signs are subtle– Mostly motor delay– Nonspecific to ASD
• Declining skills between 6 and 36 months• By 14 months, ASD signs clear in about half of
children with ASD– Low social responsiveness and reciprocity– Infrequent initiation of joint attention and response
to social cues– Language delay– Repetitive and stereotyped interests
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Clinical implications
• Screen early• Screen repeatedly in children with older
sibling with ASD• Discuss parent concerns• Early intervention
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Screening
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Who might voice the first concerns?
Parent, family
member, friend
Early Interventi
on provider
or teacher
Pediatrician
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Screening
• Need multiple approaches• Parent-initiated• Health care professional (Pediatrician)-initiated• Child care provider-initiated
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• http://www.cdc.gov/ncbddd/actearly/
Learn the Signs, Act Early
9-minute tutorial on early signs of ASD
• Autism.kennedykrieger.org
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GOLD STANDARD DIAGNOSIS 36 mos
Positive Negative
“early” classification
ASD positive
True Positives False Positives
PPV = TP/TP+FP
% with positive test results who are really ASD
“early” classification as Non-ASD
negative
False Negatives True NegativesNPV=
TN/TN+FN
SE =TP/TP+FN% really ASD who were
identified at younger age to have ASD
SP =TN/TN+FP% % of non-ASD
children identified at younger age as Non-
ASD
My data: Prospective study of ASD
• ASD n=49– At every age, beginning at 14 months, CJ and
confidence rating– Outcome classification made at 36 months
• Non ASD n=189
• All children be screened for DD during regular well-child doctor visits at:
• 9, 18, and 24 or 30 months • Additional screening might be needed if increased risk
due to preterm birth or low birth weight.• Screen for ASDs during regular well-child doctor visits
at: • 18 & 24 months • Additional screening might be needed if high risk for
ASDs (e.g., sibling with an ASD) or symptoms present.
AAP Screening Guidelines
• Parent report? Yes• Targeted ages: 16-30 months
• Number of questions: 23• Time to complete: 5-10 minutes• Free to use? Yes
– Available through the M-CHAT website: https://www.m-chat.org/
Modified Checklist for Autism in Toddlers (M-CHAT)
M-CHAT Studies
JADD Autism
Robins Study (2001)• Sample Size: 1283• Age Range:18-30 m• Well visits• Mean Age: 26 mo.• Gold Standard
– Psychological Evaluation• Sensitivity: 0.97• Specificity: 0.99• PPV: 0.68• NPV: 0.99
Snow Study (2008)• Sample Size: 82• Age Range: 18-70 mo.• Consecutive referrals possible PDD• Mean Age: 42.7 mo.
(SD= 14.1)• Gold Standard
– Clinical diagnosis based on IQ measures, VABS, ADOS, CARS, GARS, PDDBI
• Sensitivity: 0.70• Specificity: 0.38• PPV: 0.79• NPV: 0.28
• Score items: 2, 5, 7, 9, 14, 15, 20Fail 2 of these=screen positive; need follow-up.
• Interest in other ch; pretend; point; bring to show; response to name; RJA; wonder if child deaf
• Robins et al., 2010: “M-CHAT Best7: A New Scoring Algorithm Improves Positive Predictive Power of the M-CHAT”– Sample Size: 15,650– Age Range: 14-30 mo.– Mean Age: 20.6 mo. (SD= 3.1)– Gold Standard: Diagnostic evaluation– Sensitivity: 0.86– Specificity: 0.99– PPV: 0.18, (0.61 with follow-up interview)– NPV: Not assessed
M-CHAT Best7
Early Detection of Autismand Social Communication Delays
Rebecca Landa, Ph.D., CCC-SLPKennedy Krieger InstituteBaltimore, MD
©Rebecca Landa
• Screen: Social AND language delay• Set the bar low• Universal parent education about child
development and responsive parenting• Culturally competent curricula for parent training• MD training (train the eye, what to do)• EI providers: need curriculum and strategies• Flexible models of intervention• Parent-to-parent
Detect Risk, Enrichment, Surveillance, Treatment
Summary and Implications
• Sibs-A: risk for early motor and language delay• Motor disruption already present at 6 months
– Postural control– Grasping
• Object exploration and play• Some of the children plateau or decline, with
atypical features emerging ASD• Loss can come on at different times in different
children with ASD; and affects language or social
• Very few children with ASD have typical trajectories
• Even fewer have typical trajectories if sx onset is early (by 14 m)
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Implications
• Theoretical, neurobiological, clinical implications
• Early motor disruption, non specific but signal for need for developmental stimulation
• Early motor disruption– Affects play/object exploration immediately– Related to language and social functioning later
• Can’t consider standard scores• Must look at quality of behavior• At 6 months: postural control, initiating and
shifting postures (Bhat, Galloway, Landa, 2012), grasping
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